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Full text of "The Nature and treatment of gout and rheumatic gout"

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THE 



NATURE AND TREATMENT OF 

GOUT 



in 



RHEUMATIC GOUT. 



.1 - ■ - - 1 



ALFRED BARING GARROD. M.D., F.R.S.. 

FrUm if tkc Kuril CUIlm of P>Iilciui ; 

l'IiTi«duIiiKlBr>CnU*RlIii>I><tal: ■■rsdwnr Matrrii Ihdla ■nl TitnimUo. at 
UbTi CoUrii. LsDdua. 



' Olwcrrci: la utun, et luiTUB 
In routo qu'cllo votu truo." 

J. J. ROtlHEAL'. 



SECOND EDITION, EHLARQED AND CAREFULLY REVISED. 



LONDOS: 
WALTON AND MABERLT, 

l'FP£BaOWSSST£££T, AND I7T Il&NB.FATESKOSIBRBOW. 






NDUXLUII, 

s 






:v 



BnADBOBT IMO ZTIMI, mOmM, VBITUlURd. 



THOMAS WATSON. M.D.. F.R.S., 

f^matrt or tbi Mru. cotuMc or nmicuM or uMieaii: 

nmKUH IZTB4ailHII*BT TD m imKX 



Dbab Db. Watoojc, 

It is with iiloaniro I agiu) knil mjrtelfof 
the ojipononitT of expreitring my apprecitttion of tbi- 
grtmL beatAtu you' Vam .caalcmi oa the m»liuil pio- 
foMioD I7 your raltuble example, and your adminbli- 
and iDHtnictivc writin}^ — fnithcnaorc, of much pereoDal 
luDduoM (vcciTcd at your liaDd«. I coatesst that I Khould 
IwTO boen belter plowwd liad I prodanxl a work mon' 
worUi; of such a dedicatioD ; bnr, nlthaa^h moid impcr< 
Ibet, I tnut you will rvceirc it u tlic retail of a polifsDt 
inrcetij^ation into the Datnrc of a disease, wblcb, from 
the many emincDt chimtrtere irho haro boon iu marlyn, 
ffltut natorally be of flooBidenble intcKst to mankind. 

I am, Dear Dr. 'Vateon. 

Yoon vciy siaoonly. 

A. B. OARBOD. 



Ikttmhtr.lMS. 



PREFACE. 

The faToorable reception of the present Tork by 
the professioQ, and the early demand for a Seoond 
Edition, hsve Htimulated the Author to increased 
efforts to make the Book more nsofdl, by giving the 
results of his wider experience of the oatore and 
management of the diseases upon which it treats. 
Althon^ the volume is little increased in balk, 
considerable additions have been made to it, chiefly 
of a practical character, the omissions being confined 
either to historical matter, or to appended sabjects 
not of essential importance. 

During the time which has elapsed since the pub- 



ri PREFACE, 

lication of the Firat Edition, the Author has had 
ampio means of testing the vievs vhich he then put 
forward, and such opportunities have only tended 
to coD&Tm his opinion as to their accuracy. 



S4, llARLEr StBEET, CaVEKDISQ SiJUAIE, 

Deeemba; 18B?. 



PREFACE TO TUE FIRST EDITION. 

Ji» th« EDgU«h pn-ss already teems with vtnks oii 
it, it may bo expected that an author abont to 
tti tbcir Dumber, should giro tome cxplanatiou of 
kk tauooa for so doing. 

HiBTing ooiricd on a scries of inTCstigations ou 
Oont And Rheumatism for the lurt tvclvc yean, some 
of tho remltt) of which Iuito boen ulrccdy m*do 
known in tho Mcdico-Chirufgical IViujactiuns, I 
have bcvu induotd to framu the pruwrnt volume, vith 
tho Tiuw of embodying my experience in a more 
extended and coiinc«t«d form. 

The huge field o|Kn to mc as phj-sicion to a 
liOwloa hospital, hsA nfrord<<d opportnnitaos of investi- 
gBting nuuy of the important phcnomcnn of gout 
niirv minntely than could have been offi«tcd had tlio 
inqnirif^ been confined t<> cafc-s in privnto practieo; 
jud I am sanguine enough to hope that the invcsti- 



TiU 



PREFACE. 



.gations wilt prove useful in thrawmg some light oa 
, ito patliolog)', and lead to u moro rational and sac- 
DOttful tuode of truatmcut. 

The portionfl of the work in which the results nf 
my owii labours are more ])articulaily contained, arc 
tho chnptcrs derated to the condition of the blood and 
the characloM of tlic urine ; also those occupied with 
the morbid anatomy and intimntc nature of tho 
diBcnec. Tho influence of load as a predisposing 
vauso will be found dwelt upon at some length, as 
likcniso tho treatment of the chronic forms of the 
disorder. 

In conclusion, T would wi«h to cxproM my thanks 
to tlie Council of University College for tlie oppor- 
tunities afforded mo of making use of proparatjons iu 
their Auntoniical Museum for aomo of the illustra- 
tions contained in the Work. 



84, Hjlriit Stkixt, awwatata Squiti^ 
NvimirT. IMS. 



CONTENTS. 



CHAPTEE I. 

lateodaoterj ttaukt - — Eiic«lti]gt of Uia uielani writan opoo 
Um mbjMt tl OoDt— Vlon of a!ppocnUa~U«lau*— lialcn— 
AMtaoi— CUint AnnUsDiu— AUxudvr Tnlliutof— Avtiaa— 
hnliu JB(liwla — DcmttliM Ptftt^mtam—llm Anil'Iui Pb]ru- 
«Uu— Tb« prineiml Antbonof Ui* ITlh ud 18th ocDturio — 
CiMtificBlioa ot Ooul kJcptol bj diffarnt Antlion— Aullioi'* 
DiTuian 1 



CHAPIEB II. 

A«alt Omt^'DtHdpSoa of ■■ tnlr atlatk— FKnwidtMjr 
SftttptttiM B t» l aM rharMtcr tf Oontjr l>iAM*n» lira —Put 
Ant k>«teJ— Pain— (Edomk—DaiqiiuiiuloD^ Mot ftiUovcd by 
SappnntieD — Apparaal eiotptlDiu — P«brila Diilnrbuiee— Plro- 
grmt of Q'>iit^Lc» cMstnoa lomt — Acute (t'lvnl Qout — 
SeLjwlK of Acul< <i[<ut— Opiwuntu to th« dnintulitj of tt« 
McnmniN of Odtil — fijileiibuD'i dmniption of Acuta Oout> . IT 



CHAPTEE m. 

Chnale Gout r — UTot a constaat irqael to t1)« Aoota alT<ciioD — 
D«aoill4lilo of— ConutitnlioniLl Sjmptami- Altcntim of nrno- 
ton )ndao*d bj Chratilc Ooav- Malaio of t^ M-callad Cbnik- 
NhiDM or TopbaMoiu dtpouta — Their micronople and ebomUal 
ell irartfre— Their &*qiMnto«eurivnM — Siloatioa of^Upoawn 
— Often nufnl in diiagnaiit — Aimnid julnta— Wlibia bni«g — 
Caoring nndt itturm^—UioMmixt nM»— Uoalj AUomt*— 
Mt. Mmic'i dMeription cf— OutanwUnctalaBdiiic t» tb* fernin- 
lloa of HtcndTO Chalk-liltt dtpoaila— 8;d«nbam'ad«aeriptian of 
Cbnolo Qoot £S 



coirrESTR 



CUAl'TKE IV. 



Blood In Oaat-.—iiUnA «DDdiUoa »f the Blood In Qtial, cfUn 
uanincd by ihc older Wtlicn, uot proved nutd nrx ncrnllj — 
CouixuiiIUDn of the BIqmI Ui U-ullh — lu ftltomlon in Uiiat — 
Qloboli*— Flbria— All'innwi^LiKtotory of Or»U of 3o<l» in tba 
Blood — Uodo of Kiiuiilinjc Uric Asid and (TnU of Ividii rroin it 
— Olinia] Method for deMrminiaii tli« prcMoosof Uric AoJd In 
tb« Blood — DcUil* uid PrKsnlioiw — Pelioo^ of tbo Tcit— 
JImitj Doeonpodliaa of tTri« Add io tha mood— Tioliablo 
ChuiM wbioli cDiue~Tiibl« conuiniug ■ ihuil Suminuy of 
ChaM or Gout b vblcb Urio A<?id vu proicd ti> nx'nt [s tbo 
Blood — DinoTcry ut Uiic Acid id Fluid* artiAtiUlljr clftwcd — 
Vm la Di*fD°*i*— i^""'" ftii'ouat iif Unu in Urn EHiwd in Oont, 
aUo of Onlic A«id— Truw of Urio Acid ud Cna b bnJtbj 
Blood — I'ertpinliOD in Qoul — 0>&lic Add rounil in thi* Eocrv- 
tioa . 



MGS 



94 



CHAPTKR V. 



nrina in QouCr—CliVMtar ti hnUhj Urine — Tul>t« tibibiUnii 
tbo O>m|iipiitJ0D u( Uriol ftnil lb? lUiJy RliniliiBtion of lU 
diflcrent Conititucnti— Urio A(id— Tliv mujnw in wbich it 
DxiM* in tbo Grins — BeUtion bulwttu lb* Aoklilj of Vi'mt and 
lib* Olio Acid i"TtWi'"^' in it — Conditinn of tbo Uriof in Aente 
Qoat— Ho UMuif* Xmnliou of Una Arid in muiy «mc»— 
EUmlutloa nf ibc Utw bat Utile influoD»Hl— I'nne in Cbrooia 
Goal — LltfUltuC HxcTotlun »[ Oric AciJ—No muked Doflcleuejr 
la tbt KicnUd Vn» — Piti|ucnt Prescucc of inudl anaaiiu of 
Albomcn -Unnt of Gualjr linliiiiluili ia XUc intoml* of llio 
PlB — Prubablv Ei|>luialiou of tbo (roqucnl. Uoturnit uf Ouut — 
UicNOCOiilc CbuMton of tbo Diius in dlCCtrail Purine of (lout 131 



CHAPTEE TF. 



UaHoriud Anitoray of Oont ;— finat Inporttnco of tbo Sutfjtot 
— Cbwpi la tha Jolala obaerved by Porttl, hl«i«i^^ Dr. 
KaoTOt mm) oth«n-8ir B. Bmlto'i DS«Mtl«n «l a Ooa^ Sob- 
jwt— CrattiUiiM'aObwrTstlona— Tlio A n tb or'i lawrtptjana — 
1. Ohm of Obi«ni« Oont with ixltmiTo Cbalk-rttMtaitdOi^ 
tcrtioii*— '3. Solyecta oihibiijog Puinti of Dgpoattim on lh« 
Bkn tloM— 3. Chm In which no Ucixwil oc Doronnlly uhtad 
— I. WfaoB onlr the Ball of ono Gra&c Too bnd Uon kfftetod 
vitb Oont — G. Wbon ■ ilDglo AttMk of Oont bid oivarmi 
sum J 3¥ikn ]irtTiaa>ty . 172 



fONTBNTS. 



xl 



CKAPTKE Til. 



rtus 



id Amtilranj «f QvM oaDtlnstd ^— DMluakioM ctravn from tLe 
•« wUnJ la tlw Uit Cliaptar — Vnatt at tbg inraiiablo 
Pmodlb^rf Chtlhy MiHw in th« IiUUmmiUun ofTroc Uont 
— Hknasefk ud Cb«ai«kl ChsnKUn of Onolj l>epciiita iu 
iMBiiiMl 6u«clw«* — tn Ariionbr C»til^»— Rjnoiul Mim- 
btiMB — I'lbroo) Tina* — An«h jIoub of Omt Tm — CbnngM ia 
tbo K>da*r*«f Ooaty SaliJMU — 1. In iho Chranio Foruu of 
UMlU«ajiS.IaUwBurlrS(B(ea— ScpoMUinoUierfiltiulioM Sll 



CHAPTER VIII. 

{CuaHrfOont:— PraliaponBgCMM*: Bttolitarjr loHuuioe— Su 
— If» Tf PWMDWrt «r CiMiaUtiuianal Panliultr— Alealidie 
^^^wl — DinreMM in llMit Pa««r uf ImJoBing QoDt— ladl- 



■Ml>» AttiimJ OU^-AbMBM at Riiiv>H~Scrire Stodf— 

ilMtal AMktT~-a ~ 

G — t Gw> Fraqnenn 

nanbtn — InAiuno* «l th« AlKorptia ii of L«ul Dixni tht Bicf*- 



AjuktT— Cllin«l» Lnii u a I'miijipoung Ckut d 
Gat — Onat Fraqnun at Ik* DiMuc among Paiukn md 



I af Ori« Aciil — Bwilini t^iuni : Vint*, &«.— Dj*i«|itiii — 
OoM Md lloM«T»-)l(«>laJ tni Bcdil; Eidtanent or Pat'goi . S(3 



CHAPTEtt IX. 



Mbohmr or KaUiro of OoM :— KTufenoo at » doM BeluioD be- 
inw Omt (Md Crid And-~Clutae1«t« uid ConiwAUn of 
I'rw Add and Ita 8>lta-PtMl««u of ili HaUMoiTliiMla udcr 
dIAmM CBiaaiMHiiLH lt» Oeenmnte Id dlfftraat Cltmn of 
dillMli In n]wlola|le4l oad hltolcglad RolMlona— 0|JaIou 
•f Ik* Aad«Ua m U» NiUra «f Qont-Calla&'o OtiJ««tiaH lo 
lfa« DoitfiM «f Ihi Uumanl FuhologioU, aad bi* on Vi»wa 
«D iha SnhfMl— Hurts; FarlM* Thoory — Opaisa* of Sir C. 
riiiaila^in. Bu U. Bollwil, I>r. liarloir, Dr. Ourdocr, ami 
>l>an fl al1iia'» na Vifvi od ibv Xatora •( Ooat — Biplsm- 
Uoa •( (b« Ooirtj Diallitua t,ni PrmnoniMrj Sjmplom* 
itiriaaatii* of (bo I^uMfMa vi'l irartaua Fbuumraa wax d o d 
vUUtDuMM 3» 



CHAPtEE I. 

ilMBl4raMt>-8baitB«tinrof Dm T»«atauM admMd It 
lb* AB(kM*-b OMt a Canbl* DmaM F-Caltoa'a OpIaiM 
— Aalbor'a Tltva m Um ralao of UcnnliM ia Um dUtcr«t 



xii 00NTENT8. 

MUR 

Sus** of Q«at— Tmtnont or Af ntfl Ooot— IHel uul Btcinon 

— Th» Y»lup of Pufpiliics— Mewnriuli — Theit injiirioiii KlTeoU 
in taanj Cantt~U\vrel\pt nnJ Dlnijlioretidi — LllooiJ'Lcttmii — 
ColokiDDOi — Lncul TreatiDenl — Leccliei — BliflUre — W&nn Appli' 
MtioiU — Brapciriiliog Lolinna — Anodjuc* — SumniBry of Iha 
IfaMDiest cfUieOout; ftTi'ijim 311 



CHAPTER XI. 

Traitmeot of Oout. — Ool<lil«iin— Important of tb« Stadj of 
iM Mod* of Opsntlon— Tbo HenoiHliictrlui of iho AnclcuU 
mtnU; a t>|itct«i of Colchlsum — Clicniio^l CiiupoltloD of 
Odchtaam — lu PbT>iolasic>l Acliun — Cuniliv KITccu ii"t 
RxpltStikbU by ill FurpliTB PmiHrrtj^IU Inflntata oo th« 
CirooUliiig Sjitrtn— On tht Urinp — I>r. Cbriitiiun'* Kipvri- 
mnila — Obtorralinaii of PnfiBmr Chdiot — Aathar") Aualjnm 
uhiUting tbc BffMt of Colobieuia on tbo Uriag — Dcdaotiaiui 
llLenftwn— Modo of (mplojine Cokhioam b tbo Tr««tment of 
Oont— Tbc (JuoIIiiTi iliicutMii M to iti Liiibltlljr to caau Hit- 
6bM — OUnttat Pti^nnilionii nf Ci>lchieuiu — VliiU lltllcbon! 

b Qoat— Obwmiiioiu oa ita Aaiim ..... 8(1(1 



CHAriKR in, 

• 
I^Mtment of Oonl:— lu ImpOTluM in tbo Cbrnniu Sugta of 
lh« Dlioidw — Moilicitinl ■rtnaltnfnl of ObniDia Ooni — Oi^neral 
Skoleh of— Valat of HfttaM it«D*dl«t— A1ki1i<» und &Bline*— 
DllnonU—Llthln Salu pwpo » «d m CuratlTu kgaatt — Tbair 
SjieoUl Action Mid AilTU)t>|M— Anb Lar"* in Guat — TboiM 
— Tbeir Vnloa in Unutf Ou(« — Portluid Pandnr— Kiaounioti 
uf tha Likliiiitj <>f Tonic* to produco iajnrinat CaowqaenOM — 
TrtAliopnt of HffQt romplio&tcd vith Kt^tni'jr DIubuc' — Trthtmmt 
<f (h« Loml Afloctiofw— ^Bilanut — !!tilFnn» nf JomU— Chntk- 
•UbM— dooly AbwOBea— Diet lod Rt^niim in Chruuio Uout . i(!i 



CHAPTER XIII. 

TriUaent at Gout :~]11iim«1 Waton — Gcocral Rniiarka on tb«Ir 
Impbynant — AlkalSaa WkUn of Vubj— Hods of Actioa of— 
Antlior'ii Kijirriinc* uf Ibfir Vain f— Salioi^ W«tfn of Wio- 
Wlvii—Thrii Vnliic in Gnut — Sulphorfllfil ^Uuc Watcn of 
AU-Ia-ChifwIIfl — Kmplinincnt in (jncil; Cwwa — Lilhia SpHng* 
of Bkdcn Bidcn I'ud in Oout]- Cin>a— Cvlibld W»t«i*— 
InflucnM of MinFnJ Wst«B conUining little Saline Hattar, H 
of Wlldlikd, T«tiltti. ItDitoD, olc— SooiiDuy of tbo Trwtmaot 
of Uoat hj Mioiml Wktfr* 4C3 




OOKTENTS. 



xUl 



CHAnXB XIV. 



riaa 



tn lh« lBi«ill(>tlaB (f ImcaUr Farm* of Oont— Hodo it ucn- 
lihitin iW Ttv KbIoi* of DUEcvll iml AoonuJnai Cuu — 
iMnoidMt «r ItoolMia Ouul — tmplHMing tbe Stomacb, 
BtM^ ami Hnd — Oont ASTmUiik tbo DigMtin Otnuu — Tli« 
H«M^-7te BufiniarT Ois>a*^Uriiiar; CHpuii — Tbo B^v-- 
Tbe Bm~TIm Skin— Til* KtnooB ind .MdkuIht SjiUmt^ 
~ t of tb« DiSertnt Fonn* of Irngnlar OoBt , 117 



CHAPTER XV. 

! Ooot :-~B«nai1tK ea i)m Dm of tbe Kame - Conhnon 
kfUw boot tW Knplojnrat of tbo Term — Diflbnnt Mm— 
h'-^"* «nid«r Uw hnd of Hbtonktic Oont— Omm at True Qoai 
tt «Uek tba mte It (IwtD— CtaM of Snb-MoU RbtnutiHB— 
HiCDaaU of Oeat aad BbMiuUnn — O^inilu KhoBinMhiB— 
WiinMilnlrt Aitkrltl»— Tho Cbroolc EUwumitu Ailhrlti* tf 
Adiai — BodMitjr of Iho Julnu of Hajguih — Bjaptoat— 
kr— — '^' ChMuMn— 0>«M*— Patholiisj— UapioiiU— T*bla 
BsUbiliaf lh« DUbnaUil £PiwiH«U of Goul, Khminniiiia. du>1 
Ifciiii— liii I Arlhiitw— IVnUnRit of Rhtomatig tiuul—IUuit- 
tntira Cmm of BlMiinBtcid ArtkriUi 3S3 

CHAPTER XVL 



aad Ckledw— StiMica aad I«mb*c»— Kidoer IKmuo nd tha 
Smmi'Uit CoDMifWBMa of— LiAbllit; cf Gontjr fiticnu to I4 
ACkIciI ^r Lead — Pnpbjikciia TiiatmeDl of Oonl — Vmgacd* 
ofBbMuMJ Arlhritlt— rrDgnoobcf OodC . .573 



AtPUiiii 
lavix . 



018 



EXPLAKATION OF THIS PLATES. 



Pl*ti I (TiitaMi«ceSS.) Kg. 1.— Th» (or of a gonljr «ubj»rt, 
cablMtlug on* nuU ncidalc of unite of nd* upon the od$c of 
Iha Mil, ilio oal} ortamd oTidtom ot cWk-MODM riiiblo 
ihMaghant tbd body. 

Flf. S.^Tb* Mr of *90th(ir |oatr •objad, vilh ntcibI dsjicaiu oti 

Fis> S, — Tb* gnat Im of a gantj pallcD), «MiiUgnbl« doponta of 
nnte af «oda Mcn appnachini Iha nHam^ tlia tcIiu in llialr 
DtlBkbanrbood enUrgcd, kud th< wbole ton iuSui]«d. 

FuTE II. (To f*M pan IT<-)— Ths snu of b goutj mui, in wbicii 
CliBlk^luiiM had btonuo dov<i]u|>cil to an cxlmiia drgroa ; tbc 
buna oiwr Ui* olMisnon monDuuily diiUndRl vitli Glialk-Uk« 
matUr. 

PuTt lit. (To faMp*t*!<0.} Fur, l.^'Tbv UnM-jnat of n ^aty 
man, rtMsUy opened, and ciliibiting the white ploiuT'liko 
bjvt of nr*l« of njda In tbc arlkulu (sutUiige oo the bwula of 
tti* bnur, tibia, nod patella. 

FI;, 2.— Tbo w«ll«ii of a tliuab, ibowinf tho tbia layer of ilap«tft 
OB tb« aftlealar aulil^M, alio on the ligamenti^ oamiDi aaob;- 
loni^ and txtcn^ot lowardi the nnfkde:. 

F^ t,< — Tbe •totlon of a finger, cifalbltlut thu urn* pbeDomna na 
Fig. 3, in addltlan to wUeb iha niatc of aod* bu pnMdl upon 
IbepbalaneadbMuaaad ctaMd partial abaoiplioa; Mmeaftb* 
mat naU<r ia tm ptaetmtitig tba l«ao IlitlC 



KXPL4NATI0S OF THE PLATES. irv 

Pun IT. <TobeeraC*3*I0 F-ff. 1.— The bondofa inunu !aU» 
m*\j Mag* of rktnmalnd arthriluv or ili«uiuti« B<>at> 

Vtc- S. — Tbe OMUnMed Uiotj of > kbbIJ iahj«n, 

«. Bitonwl nrfkw, Rhowios tlw vartlng of tlis cortial 
jwrtloD. 

I. SMCiMafthekHln«r>al>ibr'tiDBvblt«(tTeaIuerdnte 
of (odk in lh« dirertlan ottiiv tsball iiriaif«ri, uid 
fioiaMofllittauM mnllfT ■! thn cadof ibvprnaiidg. 

fun T. (T«rM(pis«<Sa.) Fi«. 1.— A tbiii Tcititttl Mctiaa of 
Htimht «Mtibs* ttlteeUd with goalf dqioiit, txhibltlng tba 
gfTttkUiac fhinfitr at lh« unW of *ii1a, doDw lowarda chr 
ftM tdsM of Um outihfiv aud padullr b«coiiiiiig Uiitunr; 
Wrtwl lo Hit d«|«M( • Uiin I^t of orj^io nattcl a K«n. 
I liar mafri^l^ f^^r ^^■ 

. S.— A lUa fc ari aaa te l Mdnn of th« «mo cartiLif«, takoD from 
» ifWi—i tllilaai (ion a limb amputnUil hj Mr, Liinoa, io 
18<7. n* afnuifaanit of Dm djilala in lUllu Ercuja u 
»«II tbon. JJaim ptyrtr, SSO. 

Ftf, 3, — Cc7Mali of imt« of Htda frooi a atml-IIiild cTioll; coDOt- 
U«B. LioMr povn, S!0. 

■ Tlf. 4.— CrjiUllIwd Bialo «f loda, oliUliuil bj omponUnc th* 
vat«Tj aalallon «f llw Idood l» guat. Liimr pnvtr, £30. 

Flf. S. — CTrie Mid, crritalliaed an Gbn* (nm Ui« blood b |0Dt, 
Igr Um nit aad tlmad *ip<rius«. UiMt paw, lOOiad 

aae. 

J*!!. 0. — Onkia of tUcM, a7*laUia*d on a Abrt otitaloal bota the 
pmitinlAm of a gxaj oirtjtW. Ueoar powir, SSO. 

iTL <Ttofce«|ateS31.) Fij. I.— DlAttnt Ibras of erjflala 
«f wt« acU oMabwd trtm vXiat. Uotor tu**r, 00. 

tig. 1.— Cralea oftoda and ■■■wBia. 
■. Aa«t)ko<u IVra. 

(. Ciato ofaiiwah ftom arlno of Unb and nptllM 
t aad rf^ Cnua OMorring ia tiriM> 
330. 



"xvJ 



EXPL,lNATIOK OF THE ri.ATES. 



Pij:. 3. — DiOprtDt fanna of nxilita orilmc rron itrioff. 
a. The ootohodrBl form. 
(. DwltMlwdn. 

t. Tbanroid, or <loiali-l>:i11, iiuitt;. 
Uatu payrtT, S20. 

Pl|. 4. — PboiphaUi of mifnola, kumaaU, Md llmo. 

0. THiiMtie farm of tri{>t« phnplut^ Ihiffl aeabal ct 

«li(btlr ilkaliB* mill*, 
4. StelUr *Bririj. 
(. Fwllicij fbna of phupLatci Iism tlio ifllartKoil blood 

MTom. 
■J. FfaoaphaUof limo. 
liaear power, 220. 

Fig. G.— (1. Blood Jlto. 

^, Pu* MqiDHlM. 

«. Pu ooqiuMloi trtaUd wllh Milk uM. 

Pig. d.— HI. Cruulueutoof alinorj tabM. 
A. Orpaio globalw. 
(. KiilUnlial Kolca. 
LIunr ptitnr, SSD. 



ON GOUT: 

fATURK AKD TREATMENT. 



CHAPTER I. 

Iimovmoat Buuku:— Bjwwuna* or tat ikimt 'unu 
vroa TSK ttiutvt or mti— tuiv* or lurrotnuTD— <iLm 
— «*u> — iksi.«n— cituvi jieuuuiv* -• jLEXixuii t«al- 
UMn^jkKnrv— Mvic* xaiim— Pixmici mriooitHM 
— 41UI 4*iat4K mTscuH— TUB nnoiru actdois or TU 
17TII AID lerx omruBi — m-iBinoATisx or aon Atranxa 
mt Hnskcn inaoH— AmiMi'i bmnov. 

OotT is a maladj' fairly ontitled to bo&st of its 
great aotiijnit}', as it was jhtuIhiU; one of the esrtie»t 
diaoftWM to wluL-lt ilcsli beeamo heir when man began 
to partid]iate is tliu luxuiittt of oiviliiod lifo : it is a 
oUo, wliidi can lay claim to ha^-iDg had 
; ib liotims ninv of the most renowned of the 
l^nnsn raov, from their porition, opuUmcv, und intellect 
Tbv groat Sydunhum, often styled the English Hippo 
cntm, biiDHir a nattjT to gout, thus alludes to thow 
. UftUo to be ofEbetcd hy it: 



8 HISTORICAL TNTRODCCTIOK. 

" For humble mdi^duals like myself there is one 
poor cumfort, wbicli is thi^, vix. tliut gout, unlike any 
other disease, kills more rich tuud tbao poor, more 
wiw than simple. Grout kings, emperors, general^, 
odniiriili, and philosophers, have all died of gout. | 
Hereby Nature sliows her impartiality, siiiee thosoj 
whom she favours in one way&he afflicts in another—' 
tt mixture of good and evil pro-cnuDcntly adapted to 
our fmil mortality : 

' Ifltill e»l all omiu 
Futv UBlaii),' " 

Among nations in an uncirilifcd state, liiiing chiefly 
on the produce of the chase ohtoiiicd by personal 
exertion, or subsisting ou the simplest fare, gout, 
according to the reports of eminent trftvcUors, is 
entirely unlmown ; hut in our own country, and in 
many other part* of the civilised world, the case is 
fiir otlicnrij<c ; for not only is gout in its most marked 
and tj-pical manifestations exceedingly prevalent, hut 
in its lurking and unde^'clopcd forms it is probably 
still Dior« so, and exorcises a considerable influence 
over the chaindw and progress of other disorders. 

It is therefore obvioudy a. matter of the highest 
importance that the disease should bo etcArly under- 
stood in all its bearings. 

A iurther reason for the necessity uf an occurato 
study of gout, b the fact, that errors in distinguishing 
it frequently occur, not only as regards its less 
marked forms, but even its most couunun nuuilfesta- 



I11P0KTA^•CE OP THE STCDV OF OOLT. 



I 



U by no means rare, to hear of iaflammatiou 

Af B joint by one practitioner, called gont, by onotlicr 
tbeamatisni, and by & third, rbcumutic gout; and 
aaeh diflcrepaadea of opinion, of tho highc)<t import* 
nu» in treatment) oflon taiso from tbc difiicdty of 
fllaarly distinguishing its true character on account of 
our imperfect knowledge of the malady. As wo 
fvooeed, we shall be able to demonstrate beyond doubt, 
that goat is a disease tut gtmeru, baring a pathology 
of its own, and producing alterations iu tbc rariuus 
tiBsaes vhich it attacks, differing from all other 
dMngw,— alterations, indeed, which uru completely 
pathognomonic. 

ir difficitltics arise in lUstingoishing tho more 
ngnkr forms of gout, they aro greatly increased when 
its irregnlax numifestatiotu roqoiro to be discrinunatcd. 
Although in a highly gouty state of the system, 
fapctional disturbance of varions organs, and even 
mflammatory uSbctions may and do aiiso, depoDding 
npon saoh morbid state,— oooditions whoso real nafnro 
it is most important to dctermino nccorately, — still in 
jmetioa, «T«a at tbc present day, tbo tenn ^dy is 
not nnfroqaoiiUy applied, moi<o to quiot tbu patient 
and satisfy tho mind of the p]i>-sician, than from any 
imdflMN that the discoac under considcrBtioii is strictly 
oODMetod with gout; for it must bo remfimbcred, that 
flw oocurrenco of gout does not ensure exemption 
hem my other malady, and the latter, whim it arises, 
bas no necessary rolatioo to tho former. A oorcfol 
ptroiul uf th« writings of some of the authors of tho 




HWTOBICAl. ISTRODCCTION. 



last and commcnccmcat of the pa^scnt century', moil 
oooTiDCC CTcry ttiinking mind that mitny of the fonns 
of gout SCI cluboruloly described, especially by Con- 
fcincntnl pliysiaiatis, havo no rc*al existence in nature. 

It will be one object of the present trcatiite, to 
endeavour more olearly to point out and «epiiratv tlioso 
aflectioDS which itro distinctly t^iicouble to tlio gouty 
diatlieflls, to found their dingnosi» on a inoro philo- 
sophical bositf, and thus to pitvo the way for a scientific 
and sooccssJiil treatment. 

Tliat the ancients were fully cognisant of the pbo- 
DomenA of gout, and in Cnct thut it was one of the 
disorders (he nature and treatment of which were beat 
Imown to them, 15 at onco critlout fi-om a perunid of 
I- tli^ writings. It ii true that an undue stroes was 
frequently Imd upou the mere »cat of the aifection, 
and that rarious nomos were not uncnminonly applied 
to the santo disease iu its dJiferent local manifcslation;^ 
and aUo that the same name was often given to 
niuliidics of a very diverse character ; but this should 
not surprise uSt considering tluir total ignorance of 
oven the rudiments of isome of Uiqso sciencei which 
are ecsontial to a clear undei^tanding and separation 
of different pnthologiad conditions of the body. Oout 
and rheumatism wcro doubtli-M at limei confounded 
with each other by the Greek physicians, a remark 
also ftppli«iblo to some piithologists of the present 
day ; however, although the »amo general tenn was 
applied to botli diseases, still it is manifest tliat true 
gout was mostly separated froia other joint afiectioDSt 



CUS8IFICATI0X BT THE ASClENTa 



ita poeoliAT phenomcim aud progress dearly defined, 
its Tarioiu causes a««.'rUincd, uud its trcatmentf 
dietetic and modiciiud, nuefully laid down. 

The Greek ptiyisiGittiia guro diifcrcnt nnmce to tfaA 
affectioD, aoconling to itA situatiou; furcxuiuplo, v/hea 
the foot vas attacked, it mtqs oamcd I'odagm (vobiyfia, 
from ffoiir, tho foot, aud ayfta, a seiinire) ; when the 
band, Chinigra (xupiypa, from xtlp, the hand) ; vlien 
the knee, Qonagm {yox'iypa, fnjm yim, the knee) ; 
when many jointe were HiuultancoDsly affected, tho 
term Arthritiii (ifiSpoi-, a joiDt) vas more oonunouly 
applied. The word gout appeals to have le«n iatro> 
duccd into medicine ahont the end of the thirteeath 
ccutur)', by Kudulfe, and it probably owes its origin 
to the idea wliich hiui been very prcrali'nt in idl ugCf, 
that tho discuio is caustd l>y tho prosenco of soino 
peculiar humour in the hlood, which is thnnni out, or, 
as it were, distilled into the joints drop by drop ; and 
bonce in different modem langoagoe temui oxprossiiig 
the same notion aro employed, terms in fuct corres- 
ponding to our woixl gout ; thus, by tho French tho 
disease is called " Gontte," by the Germans " Gicht," 
by the Italians "Gotta," and by the Spaniards " Gota," 
and BO fortb. 

The writings of Hippocrates, who lived about 360 
years before the Christian era, afaow that ho was wcU 
aoqnainted with gout, and many of bis aphorisms 
indicate the possession of a oonsidcrablo knowledge of 
this disease. Wts find it stated, for example, that 
gouty affections aio most troublesome in spring and 



HISTOKICAL l>rTR0DUCT10K. 



autumn ; that women do not iavo gout until tlio 
catamenia have stopped ; that young men arc frco 
from the disease UU venerj- is indulged in, aud tliat 
Gimtichs are exempt from gouty affections. It is 
likewise affirmed that gonty patieul^ who hare chalk- 
stonos in thc-ir joints, and hare led a hard life, aie 
beyond the power of mcdicmc, but that under other 
droumstances tho disease may he cured by the ekilM 
phj*sician. lie considered the disoT'der as dependent 
on the retention of humours, and advised purging, 
and Uie application of cooJing agonte, orcn going so 
far OS to pour cold water on the inflamed foot. 
Although we ctuinot subscribe to oil that Hippocrates 
iKlTancod, still we must ngroc in \ua general ti-utlifuU 
DSiM ; and it must bo borne in mind that some of hia 
apliorL^ms were more correct at the time tlicy were 
ommciatcd than at subsequent periods, as luxurious 
habits had not then heou so freely indulged in. 

Celsus, about th« beginning of tho Christian era, 
in epeakiDg of the treatment of gout, remarked that 
bloeding at tho commonccmont of the attack had tho 
effect of cau^ng somo |)atient« to bo free from tho 
disease for a year, somo even for life ; ho also recom- 
mends cither cold or warm applications, depending on 
the |ve6enoo or absencs of inflammator}* actioiL He, 
however, enjoins some caution with regard to the 
appliance nf cold, and recommends a regulated manner 
<^Iinngandtheavoidanoeof corpulence. Withregard 
to the value of exercise, he remarks, " it is very necc»- 
Eary that those who aro troubled with nerroos pains, 



H 



0PIKI0S8 OP THE AKCIESTS. T 

suck W fal^jpSD citbor ill the gout of the foot or honds, 
should give the parte iiffectcd as much cxcrciso as pos- 
Hiblo, and should cxposo them on all occasions both to 
&tigD0 and cold." 

Galon, irho lived about tho latter half of tlio tiCcond 
ocntiuy, wait of opiniou, lliat gout was cauticd by Mme 
dsiiatm*! oocomululiuu of matters id the part aifectod ; 
thcte matters were Kuppowd to consist of phlc^, bil«, 
blood, or a mixture of thcw fluidis aod chalk-stoaes 
were considered to bo fonii«d by such bccouung 
oouerete or BolidiJlc<L In his comments on tho aphc* 
risms of Uippocratcfl, he remains, that though in 
thfi time of Hippocnit«s cutiudm were not afflicted 
with gout, yet thc-y vrt-ro then in consoquenoe of too 
much sloth and intcmpcnmco. Qalon's method of 
trontmont oonsi&tcd iu blooding and purging, and the 
application of ropollimts and disoutienta. 

Senoca, in his epistles, alludes to tlic iolluenoe of 
cliuge of matmors and habits, as cxem])lJlicd during 
tha Boman Empire, on tlio liability to ocrtaia discnsos. 
He says : " The nature of women is not altered, but 
their manner of Uriug ; for while tliey come up to the 
men in ever)' kind of licentiousness, they c([ua] them too 
in their very bodily disorders. Why need we then be 
surprised at seeing so many of the female sex affieted 
with gout," 

Aret«etu, tlic Ciippadoclun, who probably was a con- 
temporarj' of Galen, mid fiuunslied about the middle 
of the Kcond century, classilied all joint affections 
under the term Arthritis, yet subdi^'ided thom, accord- 



8 HISTORICAL IKTKODUCTIOX. 

iDg to the parts attacked, into Pmlngm, Chiragra, and 
so forth. That he had a verj' clonr conccptioiii and 
WM familiar with many of the phenomena of true 
gout, is evident ^m his account of the manner ia 
which it make!) its invasion. lie remarks that the 
pain first seixes tho great toe, tlicii llie forepart of the 
heel on whidi we lean, next the hollow of tho foot 
afterwards the ankle; he also states tJtnt a Trrong 
cause, 03 the friction of a new »hoe, a long walk, a 
blow, or being trod upon is often assigned, and that 
patients nro unwilling to reeognisa tho true one. Ho 
goes on to relate tliat sometimes Iho diseaso is con- 
fined to the feet during the patient's life, hat that it 
often extends to the hands, elbows, knees and even 
tho hips, and other joints; that fluid deposiLt arc 
formed which at last become converted into hard white 
tophi. It is also noted by this writer, that men are 
more frcqiiontlyiifleetfd than women, and at tho same 
tame moro slightly (tins la.^t Matoniont, as for as real 
gout is concerned, is certainly erroneous) ; that the 
most common ago » tLtrty-five, but that it may be 
sooner or later according to tlic temperament of the 
individual : as to Uie nature of the di-sease, Aretsus 
«ij-s, iiono but the gods con truly understand it. 
With rcgnrd to hi« treatment of gout, the following 
summary contains all that is important. Wliito belle* 
bore « tlio great remedy, but only in the early attacks. 
As local applications to tJio inflamed joints, ho ad^-ises 
frcsh-shora unsecured wool from the dicep, and the 
parts to bo bathed with oil of roses and wino ; poul- 



.i 



OPISIOjra OF THE AKCIENTS. 



tioes aod other irann agents are likewise rcooin* 
mended to be occadonaUy used. He further sdd», 
that the remedies for the disease are innumerable, 
for the calamity renders the patients thenuelves ex- 
pert druggistn. Arctieus eonsidera that although the 
dUease in apt to return and become chrtmic, etiU it is 
not always so, and he mentions that a goaty patient 
has, during tlie interval of the disorder, even won the 
race in iho Oh-mpic Games. 

Coiliud Aurclianus looked upon gout as hercdilaiy, 
and upon indigestion, intemperance, cold, debanchciy, 
■ad injuriee, ns the principal causes ; that the symp- 
toms usually attcndiiig persons afflicted inth th« 
diathesis, or those preceding un attack, wore a nomb- 
Dcss and pricking in the affected joints, difficulty in 
flexing and extending them, heaviness, great arcrsion 
to employment, feeling of great fatigue from the 
[(hist movemeut, starting of the limbs daring sleep, 
IttlA ^Turing, until the morbid humour at last dis- 
chai^ged itself upon one or other of the fcot. Ife was 
of opinion that the disease was chiefiy seated in the 
tendons and ligaments, and for treatment adrised the 
abstraction of blood from the affected parts by scarifi- 
cation, as less irritating than cupping or leeching, and 
Mcommcndod sponging with hot water, or oil and 
water, or decoction of fenugreek. As a rule, ho con- 
sidered that powerful purging and vomiting wcro in- 
jurious, and altogether was inclined to be sparing in 
the u»c of remedies ; he was, however, rigid as to diet, 
ndvisbg great abstinence at the commencement of an 



10 



HISTORICAL IHTBODCCTION. 



iittiick, and ft spare diet on its dooUue ; ho sito advo- 
cutod the free use of exercise. 

Alcsaader Tralliaiiu.<), m'Iio vrote in tlio siztH cen- 
tury after Christ, considers that, as there arc intuiy 
oauBoe, 80 lil^owi^ie there are nmuy varieties «f gout ; 
that lomotiincs it is oocosioncd by blood fluwiiig into 
the joints and caumg violent pdna ; at otikcr tiuio« 
b>' bito getting bctwocu the tendons and lignmcuts; 
and now and then hy tlic proeoncc of other morbid 
lluida. He gives methods of diognonng these liuppoeod 
Tarietie8) and dctaib tlieir treatment at some length ; 
when the disease is dependent on an ovcr6ow of blood, 
bleeding is ordered, but nut otlierwise ; food capable 
of producing blood is forbidden, uud striot temperanoo 
enjoined. IIo stales tliat he lias known some patients 
to have been cured by altogether abstaiuiiig from 
wine. Purgatives arc prescribed, eepedolly combina- 
tions of Kammony, colocyntli, clatrnum, and aloes, 
also tho heriDodaotylus, a variety of colchicum, the 
prejudicial effects of which ore ordered to bo obviated 
by combining it with aromatics, as myrrh, anise, 
pepper, dnniimon, ginger, and mastich. Bitters of 

I various kinds are also reoonunended, amongst wliich 
is the birtliwort, aftera-ards so much used in the celo- 
bmtcd Portland powder. Amongst local applications, 
we find tdnapisms and blisters advised, as well as 
repellent lotions; and for the treatment of chalk- 
stooos, ointments coutoiniiig oil, tui-pentine, ammo- 
niaeum, dragon's blood, and litharge. 
Actios, irbo idso lived at the end of the fifth or 



opwioys or the iSciEsrs. 



n 



^ 



beginning of the sixth cfintury, considered gout how- 
ilitary, and dependent on local dcbili^, combined 
with a superabundance of Iiuinours ; that it n-as most 
appropriately treated by first evacuating the Iatt«r 
by means of bleeding and purging, and uftonrards 
stroogthening the former. lie also attributed great 
efficacy lo the use of friction in gouti not indeed 
during the serari^ of the inflammation, but wheo 
thia bad to a great extent subsided ; ho employed oil 
mixed with salt as on externa) application. 

Paoloa JEginela likewise considered gout dependent 
DO two c<»nbtned causes, weaknces of tho affected ports 
with morbific humours, tho latter fixing thomsclvos 
npon ei>mo of tho joints itlready wcnk, and by stretch- 
ing tho ligaments, producing pain, .^gineta regarded 
gout}- and rheumatic, or arthritic complaints, of the 
oune natuiv, but diflering in the sent of the affection; 
that when it was located in tho feet only it was colled 
Podagra, but when extensively diffused over many 
jouito, Arlhrilis ; bo also thought that tho shsonnal 
httmowe might Tary in character, and when they 
bceame Ibiok or nadd, tophi or chalk-stones wore 
formed. Among the cansea of the diwaso be enume- 
rated immoderste laboar, violent walking, frequent 
cxeivise on horseback, thu unseasonable use of venery, 
oold drinks, eating unwholesome food, and drinking 
mooh wuie ; and he remarks that occasionally oeci- 
dentx, OS blows or sprains, bare indooed the fint 
attack, the malcrioU of the disease baring prorioiifily 
remained ijuiet in the prstem. Sorrow, caie, watch- 




12 



JIISTOBICAL ISTRODUCTION. 



fiilnc»i, and other pasMons of the mind, arc oIho loolcod 
upon by liim as oucu«ional causes of guut. 

In the middle or latter half of tho thirteenth con- 
tury, Demetrius repagomenos nrrote a treatise on 
gout, dedicated to the Emperor llichai,'! Pdeologns. 
lie coiLsidcrc-d it to hu occasiouud hy a collection of 
humours tuking pliioc in tlio alToetod joint, nrinng 
from imperfect digt^stiou and di'rtcitnt excretion from 
the system : the prcdiaposiiig cau.^cs being vsces« of 
food and vine, indoIcDcc, iudigcslion, retention of 
natural soorctions, and debility from o^-er-cxcrei^, 
fatigue, and too great indulgenco in Tcuciy. Those 
last operate by diminishing tho excretory powers of 
the system, and hdnce aUon'iog undue aovuniula- 
tiuns to ensue. Ilis treatment i$ both (Uetctic and 
mediciual : the former consisting in aTtHdiog indiges- 
tion, and exercising greiit moderation both in eating 
ftiid drinking; the Inttcr being cliicfly of an cracuaut 
cliarautor, either vomiting or purging. During the 
early b-tage of a lit of gout, Tcncsectiou la recom- 
mended, csiieoiaUy when the patient is plethoric. The 
virtues of tlio hcrmodactjlus combined with aromntics 
ore much lauded, and regarded as valuable, whatc^xr 
may have been tho cause of the dise&Mh 

Dr. Adams, in his valuable notes appended to the 
translation of Paulus iF'giiicta, give^ thy fuUowiug 
sketch of the views of the Arabian physicians. Scru- 
pion etrougly recommends pur^ng with myrobaluns, 
prunes, and tamarinds ; A\'iccnna and Rhufcs join 
him in praising the rirtuoe of tho hcnnodactylus. The 



orurio>"s of the ascients. 



13 






applicationa of the Arabiuos aro fiLmilar to those 
of the Orcekd : when the pain is nolbot, Serapion 
■ppnres of poimng cold water upon tie ofTectcU part; 
fihascs of biuning tho joint in some cuitrs ; Aviccnna 
of cuTcHng the part with oil and ealt, and then of ap- 
plying tho caatery. According to Holy Abba8, arth- 
diseasM arc due to collections of superiluitii^t in 
labooring under dcbilily, tbo EUporBuidos being 
|a«dDOcd by repletion and indigestion; the debility 
W tmmodenite cxt-rcise, intomporancc, debauchery, or 
suooe such cause. He states that young person^ and 
women who menstruate regularly, aro itcnu'cly liablo 
to goat, and agrees with tho nutlioritios alrvfldy mcn- 
tiooed in holding it to bo Iiercdituni'. 

When chcmlstiT emerged from nlchemr, and was 
first applied to the study of medicine, many opinions 
u to tho nature of these morbid matters were promul- 
iptted ; tar fiome timo they were regarded as being of 
B tortiireous eharocter, in many respects resembling 
the tartar which concretes in tlio wino casks. Ilieae ~ 
were held daring tho Mrenteenth and eighteenth 
Dotil tho discovery of tho tmo nature of 
vonorctious by "Wollnston. M. Coste in his 
Tnut^ prntiquo do la Gouttc," 1768, sums up the 
ideofi oommonly cutertained as to tlic nnturo of the 
guaty matter. Some, ho sn}-s suppose it to bo a 
nistnro of various cxcrementititd humours, differing 
in tlitiir (lualitio* aud uses; others a coUectioa of 
f ireiga matter*, altogotlicr heterogeneous, and by their 
omoa capabto of producing this malady ; a thinl class 





I* 



aisTomcAL UTTBODUcnoir. 



think it merely the perspiration arretted and decom- 
posed ; a fourth that it is a tnucilaginons extract 
derirod &om the solid and liquid aHmcnts taken into 
the system ; and lastly, others ssamo us that it is a 
eomhinution of miiDy euLtlo uud pciictnitiug BOlts. 
Hofitnan considered thut u salt of tartar exists iu the 
blood of the gouty, and constitutes tho prindpol causo 
cf tho diaoasc; to prove which, ho cites several 
analyses of tho concretions taken from the joints of 
gouty puttcnbt, as also cf their cTcrcment^, saliva, 
and urine, and is pcrBuadod that the taitar of wine is 
the essential matter of gout M. Costc eontcndd that 
Hoffman's opinion must be incorrect, soelug that gout 
follows almost all other ailments, and causes them to 
disappear, and heoco frrjm such reasoning, tartar must 
aljo bo the cnu.w of all these mahidin, — an opinion, 
says he, mauifestly absurd ; and aguin ho asserts, that 
gout is not uueominon among those who never drink 
wine, nnd who, Uieriifore, do not take tartar ; never- 
theless M. Coste is inclined to think that it is one 
cause of the disease. Daring the two last centuriee, 
tho most important writeis on gout were Sydenham, 
Willis, Iloffman, Musgravc, Chcyue, Boerhaave, 
Meade, Van Swiotcn, Cadogan, Forbes, and Iluherden ; 
but as wo shall hare occasion to refer to the writings 
of some of these physicians, and of the more recent 
aathon of tho present century, in other parts of this 

rk, we shall content outselvea at present with the 
I mention of their names. 

In coDoluding our sliort history, we would refer such 



fUasincATioN op ooct. 



IS 



by tlivi 
VtboM 



of our nnders as arc interested in studybg anctont 
■ttthon to Ludoo's rwnous comic poems, tbo Trago- 
podttgra luid Ocyinis ; in wliich many poinU connected 
with the nature and treatment of gout are very trutli- 
foUy, though ludicrously, portrayed, showing tlmt the 
knowledge ot thi« distxifo wiu by no means incon- 
Bdofmhlo in those remote tiinc«<. 

We havD nbctkly oUudcd to tlio divisions of gout 
by thv aaeicnts, noeording to the scat of the affection, 

to Podagra, Chtngro, Gonugra, i£e. ; tho more 
fllanifioatioiui which ono worthy of tiotioc arc 
tboM of Dr. CuUen, Dr. lla-ion Good, Sir C. Scudn- 
BuaVi and Dr. Ilamilton. CuUgq divided the disease 
into four varieties, roguhu*, atonic, rotrocedent, and 
Busploood gout; Dr. Uaaoa Good into three kinds, 
n^olar, dvguised or lurking, nod oomplicnted gout ; 
th* Into Sir Charles Scudamnro into acute, chronie, 
and retiDOCiIent gout ; and Dr. Hamilton propMod a 
ftill tnore nmpte separation, namely, into aouto and 
duronici gont. As forced attempts at subdivision and 
nfinvoient tend rather to eomplicste than render clear 
the rariooa phoaoa which n disease is capable of ex- 
hibitiog, X shall endcarour in the present treatise to 
simpliiy as much as possible, and for this purpotc 
GODsidcr that the phenomena of gout may, for all 
practical purposes, bo grouped under the heads of, 
1st, Jirgular Cfotit (acute or chronic), consisting, for tha 
most part* of a peculiar inflammation of the structurca 
within and around one or more joints; and, 2nd, 
Jrrtt*iar Chvt, which may be maoifceted cither is 



1« 



HI8T0B1CAL JSTBOCUCTIOS. 



Mverc functional disturbance of (tn)- org:an, or in tbc 
development of inflninniation in parts or tiAaucs other 
than tlioBO connected witli tliii joints ; tlie last vari«fy 
would therefore include the vniious forms cliLSSed by 
different wntc-rs under the beadB of atonic, mii^laoed, 
retrocedciit, lurking, abortioular gout, &c 

Many duscases which have been grouped under 
these various denominations hare no daim to be con- 
sidered truly gouty, being frequently but the seoondaiy 
effecffl arising from olterationH in organs, induced 
eithor by gout, or by the causes which ha\e given rise 
to it. 

Some objection may perhaps bo made to tho use of 
the tonus regular and irregular gout, and it may bo 
asserted, perhaps with truth, that its eo-called irrL-guIar 
manifestation.^ arc in fact quite as regular fis tlio arti- 
cular affection ; howovor, the terms are convenient, 
and the meaning to bu uttochud to them has been 
sufficiently esplcuncd. 




17 



CHAPTER II. 

Awn Doot:— DHtnnmoN or *» k»iii.t *it*«»— »«i(o)!itobi 
arartom— «BAT >«> onmjtorKH or «o«tt atLtunknwt — 
rAU ram tmattb— not— aas*A—vt»iiBuiim>— not 

MbLOnD » RPfDlunM — JLVMU-TT IKCrTldM— riia*ii.K 

£UTcut*n — rsMUM m a*^—!** ouudji rout»— loprit 
oxnuL ttoot ii q pM.* w tovnt oon— orwMra *> to ru* 
Mvuuaturr or mi: ocmuusci or com — trauiui** 
tmiumoN or .ionx <toci. 

TuE plionomvua attondiag aa acuto fit of gout liavo 
been freqiuiiUy and ably described, espcctaily I>y 
S}'d«Dhain, irho Iiad, in tbis respect, tho (luCftionablc 
tdrantflgc of bciiig iiblc to njooixl wbut lie biiti.sc'lf 
both fvU And obscn-od. ^Utliough unitlilc from ]>cr- 
BODal «ipcncDoo to describe tbe acnsatiotu of gout, I 
vill MtdOAvuur to depict ibo pbonomcna vliteli bavc 
OfRialt}' oomo uudor my own ub«orvatiuQ ; the dc««rip- 
tiou refcrriug moro c$peciidly to tliu first, or, at uiiy 
lato, an enriy uttook of tho disease, and one oninflu- 
enoed by the cxliibidou of medicines. 

An individual, in upp*rently good health, perhaps 
even flattering himself that he feels onusually woll, 
retires to bod ; after a fuw hours' eleep (gcneridly 
from one to four in tho morning), ho suddenly awakes, 
with a pain, more or lea intoow, in tlio ball of one great 
toe, frequently aocompsuied with a slight ehivcritig ; 




18 



ACUTE GOUT. 



ilie pain in tlic foot graduallir increases, and is nttendej 
villi a sensation of burning and throbbing, together 
with great tension and stiffness; some heat of skin 
and other eymptoma of febrile disturbance usually 
follow the shivering, with a considerabte degree of 
nstleesnoss. After a few hours these sj-mptoms Bomo> 
vlwt abato, ennbling the patient to enjoy a little ale^, 
and a gentle perspiration ensues. In the morning tho 
toe is obsonrcd to be swollen, tho skin of deep rod 
colour, tense and shining, and tlie whole juint ex- 
quisitely tender; the veins proceeding from thelnflsmcd 
part are distended with blood, producing alight lindity, 
and an appearance is exhibited closely resembling the 
drawing in Plato I. fig, 3, with the exception of the 
white spots, which in the delineated too arc duo to 
dcpoists of urate of soda from oft-repented fits of 
gout. 

During the height of the attack the pain and sensi- 
bility of the affected part are usually most intense, to 
sudi a degree indeed, that tho patient can neither 
bear tho weight of the Led-clothes, nor even the 
shaking; of the bed from footsteps in the room. 
After 8 few hours of torment the pain generally 
Abates, but this is not alwaj-s the case, for, if 
the attack be vciy severe, the symptoms may con- 
tinue, though ■with leas intensity till tho evening, 
when they again increase, and the second night is 
passed in a state of renewed restlessness and suffering, 
irhich abate only with tho dawn of day. Tho third 
erening the symptoms probably return, subsidiug the 



DBBCRimOK OF AS BABLY ATTACK. 



10 



fulloving momiDg ; and tliua Uio pEilicnt continues to 
giiflcr mnuy <luy«, occasioiiully wc«k.s Uio duration of 
the attuck do]>('iidtiig on vnrious drcumstanoes con> 
Dcctcd vitli ibv coBdition of tlic sufTcrvr and tbc mode 
of tniltincnt adopted, Lotb as regards medicine and 
rtiguiioii. 

At tlio time of the greatest febrile disturbauco, the 
nriuo is usually K^niity and high coloured, occasionally 
romaining dear, but for tho most part giring rise to u 
dark reddish hnvt-a tKnlimcnt on cooUug. The appe- 
tite is generally impaired during the severity of tho 
pain, but it may be as good as in health, nay, some- 
times augmented ; thint is present when the inflam- 
nution is severe; tho bowels arc o^ii constiputod, 
iBkd the paticitt liable to bo oSected with sercrc 
cnmpa id the muscles of tlic legs. 

WhcQ the attack, or as it may ho perhaps more 
properly called, scries of attacks, is aboat to tcnninste, 
tliO inflamed part gradually bcoomes lest tcnu aad 
swollen, pitting 19 mors readily produced by praamr^ 
the reduces and eoUrgoaont of tlie blood-^-eeseb dis- 
•ppcar, and afler a few daye, itching of tho skin and 
desquamation of the cuticle ensue, the joint remaining 
more or less tender. 

In the first fit of gout and frequently for many 
attacks, tho hall of one great too is tho only joint 
implicated, but occasionally the inflammation suddenly 
kavcA this toe, and tho contsponding part of the 
other foot becomes affected ; sorootimos th^ inflamma- 
tioo trarck to as to implicate the inner side of the 

3 



» 



ACBTE GOUT. 



foot ; ^ut t]ic«o instances furm the exception ratber 
tlian tliti rule, and mil lio fully ilc^ribcd vhm vn 
have occasion to dwi-U upou tlic individual s>'Tnptoms. 
The above dc-fcriplion refcra moro particularly to the 
first few attooks of gout in robust and othcrwiso 
licalthy 3ubji,-ct'<, and nifiy be talcen as typical of aeu/e 
liAeiiic gout ; but now and tbcn, es]iociiilly among 
iromen, an acuto fit may be wanting in many of tbcso 
symptoms; there may indeed bo pain and tenderness 
in the too, and some nmouiit uf swelling, but accom- 
panied witli Little heat or rcilnesd, and all fcbrilo dis- 
tnibance may be ab.'^.'nt, still a'dema is gonoroUy 
obserred, and itching and dewioamatiou follow ; this 
Utter form, which may bo considered as rejtre-wuting 
aenfe mt^nic goat, is doubtJcst of the same nature in 
its essence or pntliology as sthenic gout, the difference 
depending mthcr on the cbaructcr of tlio patient in 
wliieli it occurs. Astlienie gout, although at first 
apparent3y mild, may ultimatdy proro more mis- 
ohterous than the sthenic form, &om its lusuming a 
chronic type, and is often attended with cooscqucnoes 
fbr more injurioos than the severe and painful fits of 
gCDuine sthenic gout. 

Prior to a firet attack of gout there is generally an 
absenco of any prominent premonitory symptoms, 
although disturbance of tlic fuiicdon of some oi^an 
would probably have be«n observed, had the patient 
been narrowly watched for a few days pnwedisg the lit ; 
hat in suhse<[ucnt seizures there arc osoally nncom* 
fcrtuUo aniittioiis oxperienood for a short tunc pre- 



ntOIOSlTOKY SYMPTOJIS. 



n 



Tiouslf, mostly referable t« tlio digestiro organs, os 
Iimrtbura, addih', flatulence, opprc^wu aad <lrowsiuo«s 
after talcing food, litccup, ecaaty and high-coloured 
urine, but saittctimcs copious nnd pale, coiiilnod bowels, 
loss of appetite, lowncsis uf Bpiritj), and a fueling of 
luritodo. When individual* ore liable to weakuea 
or disturbance of nay organ, symptoms rcfcniblo to 
such are apt to mARtfwt thcnuelros; for example, 
somo experience palpitation of th« ImmtI or intcnuis- 
aion of the pulse ; some arc troubled with liomiorrboids 
or irritabiU^ of the bladder; othcra are annoyed 
with excessive cramps and itdiing of the ekin ; the 
temper is often much ruffled, and the patient bocomee 
pocTJfih and irritable. If subject to bronchitis or any 
other chronic affection of the chest, an increase of 
cough and d;-spna:a may precede a fit, and bo greatly 
relieved on tlie occurrence of the gouty paroxysm. 

Sodi are the sj-mptoms which aio commonly ex* 
perionced, and may perhaps be fairly dasscd as pre- 
monitory of an nttaclt of gout. 

Havbg given a gcnei-al sketch of a fit of gout 
presenting the principal characteristics of a typical 
attadc, iro will enter a littlo moro fully into the con- 
nderation of the vorioos phenomena preriou»Iy 
alluded to. 

Tlic first point to bo soticod is the tail <^thf tifffc 
tiotu We have said that it is the bidl or metatarso* 
phalangeal joint of the great toe, and unless there are 
oircunistanccH in the cnso whicli have, as it were, 
thrown the disease upon eomo other joint, circom- 




» 



AC DTE GOITT. 



stances wliicli we sltall liavo prcst-ntly more particulnrly 
to notice, true gout, at ib; first in^*asioD, seldom attacks 
any other part, and even if anotlior bo firet affected, 
the boll of one great toe is probably so likowiisc. Sir 
C. Scudnmoro drew up a list of 616 cases of gout, for 
the purpose of determining this point ; and &oni tluB 
table wo find that ouc or botb of tho groat toes alono 
•wem afibot«d in ^l ioxtiuicos, and the groat too with 
aom« ether part in 373 oosoe. Tho details of tUo 
tabic arc seen below. 



In thcgnal to* of ono foot oslj .... S14 

In Um (iMAl IM •}( tmh frnt • S7 

In the Imcc uid gctmi tso I 

In tli« little CM Bcd ono adjoloing I 

In tbo great too uid lixlcp ..... 4 

Is tfat limit la**s(l !ntl«ii otwidi foet ■ • . 2 

In till) urisl too oT ono Itol oml itattp of lIis otbor . I 

In lli« gn&t toe. in«tv|^ and ankte of ona (bot . . 1 

In tuh gnu IM knd ttnh hand .... I 

Id Ilia •narn&l ilde of tbo foot Mid Ui« great 1«« . . 1 
In tht «t(*rnkl «id« of one foot and Um iniit tog of th« 

alb«r 1 

In the lieel *iid th« gnab tae 2 

Is tho aokle of one foot uid the grott t«c i.t tlio etlier . 5 

In the nnklo and great too of tho mdib fool . . . 11 

In tho tcDilo AohlUi* uid tbe grwl tM ef the Mmo liiob 1 

In tbv outer Kids of oae foot 10 

In tho DUlci tido of ciuh foot 1 

In tho sole of tlic foot ...... 4 

In the btcl of ono foot ....... ft 

Id the heol of Meh foot S 

In the b*«l Md iniil«|i of th» nm« toot .... S 

Id the heel ot eeinh foot, in ouh bond and enoli elbow . 1 

In tbo bUD 1 

Xu llio knee • • .11 

lo *aeb kao* 1 



SEAT or TUB DISORDEU. 



sa 



iDlhaluUpof oiMfoot a 

Id lk« iniUp oleuh fiMt 

In one 'uuUf &nt, »(lerwarJi weh ks««, t*eli writl, 

Mch «lbaw, ud cMh ilooUcr ... 

laoBftiaU* Se 

Innrbukl 

Id (hauiUc uil iMtop oToM ftiot . , . . 

)o lb» Undo Aohillii 

Id Um Undo AdiilJU Md utVle 

CUfofUMhs 

In the Xhvah, kae*, ankle asA pMt Im oa on* tide, 

udbudy, ihesnUIMrf ifaeotbarfoot. 
la the tigbl knw aod Wt hud •* the nme tUoe 

In tlie book of one haad 

la Ike TO»i 

ThiUDb aud hand 

la the tbunib 

In twu middle Cnjen 

In cae middle ftot^r 

la Uie JoDttb 6DgtT 



Hy ava expericnoo fully confimw tbo rosolU of tho 
above table, citpcciitlly as to tlio frequency of tfao great 
toe being selected ; aud I am cunviuocd that iu nuuiy 
oases of joint aSV-clion, whcro difficulty wuuld otlit-r- 
nm exist as to tho procise natoro of tlio discuso, con- 
ddcrabto light may bo thrown upon the subject by 
directing attention to tbi« fact ; it appears rcmarkablo 
that this particular joint should bo tiolecte^l by tho 
discoso upon which to rent its fir&t fury ; however, so 
it is ; and when wo shall again hare occasion to rocur 
to the point in diacusdng the nature of goiit> wo may 
possibly be able to give something like a rational ox* 
planation of this phenomenon. From an iuretdigution 
of the history of a eonaideraUe number of cases of true 



H 



ACUTE OODT. 



gout, I Hud tlint in not more than five per cent, were 
other joints slut«d to be implicated, to tlie exclusion of 
the grvat too ; and authors, both in this country- and 
abroftd, aocm to be fully a^eed upon the tantt^r. In 
point of frequency in being nttackud, the wiklo seems 
to bo soooiid to the ball of thu grcnt too, afterwards 
the instep, next the outer side of tlio foot, tlien the 
knee, &c. ; vhcrcos, the upper extremities arc seldom 
implioatod i» tlic curliur uttucks of the disease 

The extreme frequency of tho affection first locating ^ 
itself in tho btdl of tho great too canaot ho looked ^H 
npoa OS a mere fortuitous circumstance, but is inti- 
mately connected with die pathology of the disease ; 
when deviations from this rule are found, they depend 
on peculiar influonc«s which are then brought into 
oporutioa, some possibly existing within tho patients 
themselves, but pt-rbnps more oouunonly arising from 
without ; tho most potvnt cause of such deviations is 
the ocourronco, cither at tho time or oa some prior 
oooiMon, of injuries, such as bruises or sprains. 
I possess Ifotes of cases more or Icjs resembling 
tlie following: A gentleman, with a strongly marked 
hercditan- predisposition to gout, hurt his knoo from 
a fall nheii hunting; the pain was not very sorero at 
first, but in the course of a few hours became intense, 
much moro so than could bo accounted for by the 
nature of the injury ; it soon, however, became evident 
that the j'>int was affcctod with acute gout, which n-as 
q^ccdily relieved on tho hall of the great toe of the 
some side becoming inflamed. Ahet two foal's^ thia 




CHAIt,lCTKR OF TBB ISFLAMMATtOS. » 

potienf hsd n socood attack of gout, ^iliich was tfaeo 
i3onfiiic<d to the 1>aU of tbc great toe. Sir C. Scuda- 
morc relfttoe the foUowing case : A gentlemut, yrhea 

I youtlt, accodeDtaUy receired some Rmall shots from a 
. in ODO knee. Tlioy wera rcmoTod, but the knee 
'Was rendered iwrmanriitly weak ; aiid to this injured 
joint gout, in nfltrr life, first attached itself, and always 
nAvnriirda with m»ro severity than any other atail- 
tion. Ifanr other ciamples might be quoted, illus- 
tratiTO of the influence of local injury- ia causing gout 
to appear in parts not usoally first affooted, such as 
the ankle, elbows, &c. ; but us we shall again hare 
ooondon to rofor to this subject when faking of the 
exciting causes of the gout)' paroxyem, wo will fiontent 
outhcItk! with the instances abo^'e giren. 

The characttr of fhe inftammation next dcsorres our 
ntion. Wo hai-u said that there is much pain, 

ad there appcnm to lo Bonotbing peculiar about this 
Rjinptom ; it in oHen wry totensc^ and differs con- 
siderably from tliat produced by injury ; a gentlenuui 
for example, who broke his li^ and then had a fit of 
gflut in the opposite great too, expressed his opinion 
that the pain of the latter &r exceeded thai of the 
former. Sometimes it is described ns resembling the 
gouving of the part by a do^, the diiilocation or tear* 
ing <rf the joint asunder, and so forth. Dr. "Watson, 
in his admirable Lectures on the Principles and Prao- 
tioe <^ Physic, gives the description by a humorous 
Frenchman of the distinction between the paiu in this 
disease and in rhcumatiam : " Place," says he, " your 



H 



ACUTE GOUT. 



joint in a vice, and screw ihe rice up until you can 
endure it no tougor, that iniiy rcproacnt rhoumatism ; 
then give tlie iuittruniuiit another twist, and you will 
obtain a notion of gout." Now and then, indeed, 
caaes of gout aro mot with, in which tlio paiu docs not 
apjKar so intense, eUthough llio tiiflummntion muy run 
high, and I have kiiuvni sevcrul first uttucks uf tbo 
diaeaao in which this has occurred; they form, how- 
erer, tho exception rather tlian the rule. 

The production of a<lcii>a of tho gouty part, niid Uio 
subsequent dmquamaiion of the cuticle, I* a peculiarity 
of gouty iuflammntion when it attacks supcrfJcinl 
structuro=i, nud one desorrtog attoution ; for although 
it cannot by any means be considered us pathogno- 
monic, fltJU it is souietiina'i of considerable value in 
dingnosU. During tho early stage of an attack, when 
tlio inilammiition is violent and the skin distended 
and shining, tho oedema cannot be readily obscrvod, 
on iiccount of the tension ; when, however, Uie iuilam- 
mation begins to subriidi^ pitting can bo easily detected 
and tho presence of fluid made evident. As a rule, 
true rheumatic inllamuiation is n<it aeconipauied by 
ccdema: but it now and then occurs in undoubted 
caacs of tho Bcutc disi-ase ; it is, howercr, more gene* 
ral in character, affecting the whole limb, and not BO 
strictly coniincd to the inflamed part, as in cases of 
unuomplicatcd gout. The desquamation of the cutido 
is a subsequent s^'mptom, taking phtce after the com- 
plete subsidence of tho gouty paroxysm ; it is most 
usually observed about the fwt and hands> rarely in 



COARAcrmt OF TUE IXFLAyMATIOir. 



17 



tiio kneos; it seems, as &r as my own experience goesi 
to bear eome lelatioa to the amouut of the prgvioas 
aylcma, aod consequent distension of the skin ; ooca- 
sionully orcn the naiU have been «bcd after n sotctq 
attiick of goat : prior to and accompanying the desqua- 
mation there is often considprable itching ; a symptom 
which follows other flight injuries to tlie skiui as the 
applicatiun ot a blister. Sir C. Scudamorc obscrv-ed 
that in 334 ouiv, eeTent}--c^ht patients never expo- 
lUnood dosquamatlon, and in my own Kotos I find 
several in which this symptom is not mentioned ; but 
it must be remembered that it is ouo readily over- 
looked, onlesH specially sought for. With regard to 
the canse of oedema occurring so frequently in gouty, 
compared with other fonns of inflammatioa, nothing 
very satisfactory has yet been made out : may it not 
depend on the impuridai in tlic blood ¥ U«y not iho 
preeenoe of urate of soda and a small amount of urCA 
in that fluid, be at least one cause !* As wo proceed 
wo shall discover that tho blood in goat differs much 
from that in iheumatism, especially as regards tho 
presence of thc6o exdementittal matters, 

ITpon tho temperature pf ike parti affected with 
gon^' inflammation, there is nothing of importance to 
remark ; patients often express themselves us suffering 
from intense he»t of the joints, hut tho tbermonictcr 
shows no greater increase of temperature tlian is 
ordinarily found in many other fomu of inllanimatot; 
disease ; the extraordinary ecosatioa of hcet, tliere- 
fore, whieli is sometimes felt by the gouty, must arise, 



es 



ACUTE conr. 



not alone trom increase of Utmpcniture, but from a 
poculinr cxnltution and pcn'cr&itfn of the nerrous 
function. 

Qouty inflammation dilTors {mm common pblegmo- 
nouA ioilamiuation in eomo other important points, 
and more ciq>eoially in hoI being /ollouxd hi/ suppHra- 
lion. If a mcdioal man, by chiince entirely ignorant 
of the natoTO of goat, vere to see a toe affcated with 
this disease in its full iotenfiity, swollen, hot, red, and 
tender, ho would probably think that tho affection 
must of neccssit)' tenninitto in suppuration ; yet I 
beliore this never happens as the result of simple 
gouty inflummiition. I have, it is true, wen cases 
which at first appeared to favour the idea that suppu* 
ration somctinics thus occurs ; but, on further investi- 
gation, in each instance the formation oS the matter 
could be oUicrwisc satisfactoiily accounted for. 

The following case illui^trntes Uieso remarks. A 
man, C. F., was attacked with a nolent fit of gout, 
affecting many joints, and, among others, tbo first 
pbalangenl joint of the right index finger ; the swell- 
iug rapidly increased, wa.'t accompanied with much 
pain and redness, and in the course of four days gave 
distinct evidence of the presence of fluid; a small 
puncture vttn. made with tlie point of a lancet, and a 
drachm or more of a milky-looking liquid escaped, 
eontaining pus globnlc», mixed witli numerous crj'stals 
of urate of soda aggregated in small mosses. It was 
■Jtervurds found that dopo^iit^ of tliis salt had pre- 
viotuly oxistod in tho port, nod the suppuration was 



1 



CHAIUCTER OP THE INFI^VMUATIOX. 



» 



doubdess owbg to the inflamnuiHoD occurring aioiutil 
It foreign body. Sir 0. Scudamorc eUtco in hu n'ork, 
Uiat ho only found stippunktioD in eight cities, and 
DOtiocd that in cim^ iastanoo th« rtsnlt was curitnuly 
modiEod by nn nttonduit eocrotion of oreto of soda : 
I belicvo tluit in ull of tlicm, had thoy boca specialty 
exasuDod, it woold hnvo been found that urate of 
soda vns prermUBly prcacnt io the tiasoM, as tho 
result of former attacks. I ha\-o lunTr witseased, and 
am not awBre of there being an example on record of 
a Jini Jit of goat, hoircT«r intcnac, being occompaiued 
with the production of pus. 

I believe it may bo considered as tlu> rule, that in 
acato gouty attacks tho amonnt ot/ebrUe ^i$iMrba»<x, 
08 indicated by the rapidity- and force of the pulse, the 
inereaKd Iwiat of surface, Uiirst and loss of appetite, 
bears a eloeo relation to the extent and flevcrity of the 
local inflninnuition ; that tlio fever is, in fact, chiefly 
synptoinatio, and differs greatly firom that vhidi ocoun 
iu acute rheumatisni, wliei) the highest febrile dis- 
turbauce may exist without any proportionate inflam- 
mation of the joints. Although the tkin is frequently 
moist during an attack of acute gout, ^itl tlie |irofa<!<o 
and peculiar sweating so commonly met with in 
rheumatism is never prcttcnt. 

The following cases illustrate the doM relation 
existing between tho febrile disturbaace and the 
anonut of local diseusc. 

January, 1855.-11. C, »tat. 32, had his firet attack 
of gout, when 28 years of age, confined to tlte boll of 



30 



ACUTE GOUT. 



the left great toe, which iras hot, swollen, and poioful, 
ttftcrwai-ds pitting freely on pressure, and giving rise 
to dcstiuamation of the cuticle. For two ycara after 
tlie iirst fit ho had a rctuni each year abuiit Christmas; 
but witliin the last two years, an additional onu in the 
eummor. The fits gradually increased in severity, and 
the number of joints implicated becamo more numer- 
ous at I'lich viiiitation, "Wlieu first visited, tbo ball of 
the loft great toe, instep, and uukle, wcro swollen, hot, 
and painful ; with the corresponding parts on the 
right side, although in a less degree; the wrists, 
hoiids, and elbows wore much inflamed, and the 
knees were slightly affocted. 

This case affords wi example of acute gout aiTccting 
many joints, and the febrile disturbance will bo seen 
to bo of corresponding intensity: the pid^o for ex- 
ample was hard and full, lOS ; the skin hot and dry ; 
the tongue furred, with much thirst. After a few 
days* treatment, the joints wero relieved, and the pulse 
became soft, and only 74 in tbo minute. 

Tlic next cose presents an example of the aoute 
affection in which ow joint only was implicated. 

November, 1854.— J. P., rotat. 44, had his first 
attack of gout at the age of 40 ; the second, two years 
iifterwards, the present being his third fit. Is now 
complotning of great pain in tbc boll of one great toe, 
which is much swollen, hot, red, and pitting a little 
on prcfuiirc- Tongue furred, and slight tliirst. Pulse 
78, and no other symptom of fever. 

It will be commonly found that in cases of gout, 



pnooRZss or the disease. 



n 



wfa«n bat few joints are affected, tlie puUe, if not 
qiiiclcened by the intensity of the pain, is but Uttle 
ocoeleroted, nor are the other signs of febrile diistiirb- 
aii«e at aU prominent ; nmch stress cannot bo laid 
npon tho condition of the tongue, u this di^icods 
greatly upon the state of the patienfa stomach and 
bowels, organs {rctiuently deranged in gouty inditi' 
dtiii1«. 

Having ehowD tho most important phenomena 
nsually nttcnditnt upon a first or early nltack of gout, 
wc will noxt ondearoorto trace the further progrosB 
of tho discnso. OccAHonally a pnticut cxporiciic«« but 
a single attach of gout, but thin rarely happens if his 
life in prolongod ; commonly tlio distasc rclumei after 
an interral more or loss lengthened, depending on tlio 
patient's coDJ<titutional tendcney, his mode of living, 
and tho amount of predisposing and exciting cause* 
to which he is subjected. Several years sometimes 
elapse between the first and second lit ; frequently two 
years, more often one, now and then but a few moiitJis 
respite is aSordcd ; as the diacase becomes grafted into 
the constitution, the attaotu are frequent, and at tho 
same lime more general in their cliaractcr. "When 
gouty patients live within moderate bounds, and when 
the hereditary predisposition is not very great, the 
iliseiLEo may be confined to the ball of ono or other 
great toe for several attacks, or even for a period of 
many years, but the tendency of the disorder is to 
travel upwards, affecting fijst the ankles, then the 
knees, and afterwards the hands and elbows, and still 



3S 



ACUTE GOL-T. 



Inter the joiut< of tlio upper cxtramlties. So Eroquently 
ia this order of succcs^iou met witli m true gout, thtt 
the history of a ca-ie mil oftou servo &8 a guido in 
arriving at a correct diagoosLi of tho disease. 

My Xotc-books affoid numerous illustrations of 
wliat I haro now stated ; it will lio suffioiont> lioworer, 
to giro shortly tlio details of the time and situation of 
the attaclws as they occurred in a few instoucoa ouly. 

1857. — C. M., totat. 55 years, not inlit-riting goal 
from either father's or mother's ride, but having a 
brother slightly affected with it. Fifteen years ago ho 
remembers going to bed quite well, and about (bur 
o'clock in tbo momiog waking up with pain and stiff* 
ncss of the boll of tho right gn-itt toe, which soon 
became hot niid swollen. TIio lit Iiistod about threv 
weeks, and no otlicr joint was implicated. 

Tho seoond fit occurred at the end of a tvelro- 
month, affcctiug the same joint, at the same time in 
the morning, and lasting altogether about a fortnight. 
For the next six years, tho attoeks occurred annually, 
and were coofiued to tbo motatam-phalangeal joint 
of oue or otLer great toe. 

Six years ago, the upper extremities fit^t bcoiuno 
implicated, tho disease attacking the viists, knuckles, 
EUid phalaugcal joints; the paroxysms usiully la»tod 
about fourteen days, and were followed by desquama- 
tion of the skin. Until witliiu the last t%t'elTO>months 
the fits have returned unifonnly at tho samo time of 
the year, hut riuce that period they hare been moro 
Sequent and uncertain. 



EXCETTIOXAL CASKS. U 

It is indeed astonishing to find how regularly, in 
sonui instances, the returns of goat uccur, for uot un- 
fteqacittly patients are aUe to ooleulato the time, otcq 
vrithb u few da}'8. 

Tho fullowiug cost! is an example in wliich for many 
}-cars the intonmls between the attacks vhiq long, 
and, at tho same time, rciy regnlar. 

1861. A gentleman aged 49 yean, who cannot 
trace gout to any of his ancestors, but who has always 
lircd well and portukco fredy of malt liquots and 
wine ; mth the exception of goat has always enjoyed 
good health. Uis firvt attack occurred ten yean; since, 
and was con&iL-d to tho boll of tho right great tuc ; 
two ycAis afterwards, tho same joint was similarly 
aficctcd ; two years again dapsod between tho second 
and third fil«, and a iiimilar interral between tbt 
third and fourth ; tho disease being as yet confined to 
the ouo toe. In the year, ld<i8, tlie left great too and 
iustcp were affected, and in 1859, tlio right too was 
again si^octcd ; in 1^00, both great toc8 wore impli- 
cated couflcoutively. After thif, gout beeaino more 
frequeut, and within the last six months ho lius suf- 
fered from three attacks, sometimes in one foot, some- 
times in both, bat the knees and upper estremitiefl 
hare rcmoinctl free. Tho urine is usually clear, oon- 
iaining no olhumi-n, and gives rise to a veiy moderate 
deposit of uric add ou the addition of a foreign ncid. 

I may odd, that under treatment this patient soon 
became free from gout, and has remained co for a 
pciiod of nine months, having passed tbiough a sereco 



A 



Si 



ACUTE GOUT. 



ordeal during tlio Hutuma and spring. Tho long 
interrols which occurred m rcpoutudiy m Uio above 
OBse, may be esptained by tbe absence of any heredi- 
tary predispositioQ, tho possession of a good constitu* 
tion, and tho ago of tho patient, and tho check given 
to the progress uf tho disease is duo not alone' to 
modioinal trL'atmcnt, but to abslincnuo from tho chief 
predisposing itnd exciting causes. 

Tho next caso illustrates among other points, that 
Bometiincs very long intcn-als may occur. 

Oct. 1861, A gentleman, ffitat. 50, inheriting gout 
from father, had his first attack ichcu somewhat young, 
in ono great toe ; after many j-cars tJio second fit 
occurred in tho sumo joint ; then, after n» interval of 
four years a third, uud a fourth about tlirce yoon 
aftornurds, and so on for six or seven attack.* ; up to 
thi£ time the disease had been mild, of short duration, 
and hud confined ita^ to tbe feet with one exception, 
vhos tho knuckle of the index finger of one hand 
was implicated. In July of this year a more severe 
attack came on, first in tho loft heel, then in the left 
great toe ; aftcnrards in the right groat toe, and 
during Augn.st the same succession was repeated ; in 
September, tho heel was for tho third time affected 
and one toe; he has now scarcely recovered. Ni> 
dyspeptic symptoms aro present during tho gout or in 
the intervals, but the padent is subject to cold extre- 
mities and shows other evidence of a feeble circulation: 
is vor)' careful as to diet, takes a little claret and at 
times cidor, but no molt liijuors. It would appear 



J 



ESCEPTIOITAI, CASia 



as 



that licrcditarT tendency is the chief cause of gout in 
this insiance, and tho lengthened inferrala may be 
nttributed to the careful manner of living ; howerer, 
at the age of SO years, the disease is apt, unleaa 
checked, to become more firmly rooted in tho system. 

Hie last case is an instonco of the opi>osit«; kind, in 
vhich tlie attacks o( gout &om tho fint comv on vith 
great rapidity. 

188!!. A gentleman, i^^ 40 years, haTing no 
known hcroditarj- predisposition to goat» and norer 
having indulged to any extent in alcoholic boriirages, 
was lirst attacked in April, 1861, in the ball of tho right 
great too, which wn.i swollco and [tainful, the nttack 
lasted about a fortnight, during this time tho leA toe 
vas somewhat implicated. Three nontlts suhsoqaont 
to this tlie second lit occurred ; four months ofler- 
wuds, th« thini, and the fourtli after an interval of 
two months only, in all of ihc^e attacks, the disease 
was confined to on« or other of tho great toes. It is 
(Ufftcult to divine the cau.<w of tliU rapid derclopmont 
of the sfTcction, as tho kidneys aj^enr to be frc« front 
disease, and no marked dyspeptic symptoms hnro bocn 
observed. 

AJtbongh it gcnctully hnppena that Ibe great too is 
first affected in gout, or at least becomes implicated 
during the progress of the fit, this is not in^'sriably so, 
and we must by no means conclude that a disease ia 
not gontj-, simply from tho ahscnoo of the toe affec- 
tion; for now and then striking eiamples prosont 
themselves of genuine gout, the great toe during tho 



35 



ACUTE COtT. 



whole time remaining i^uite fi-ec : tliesc iiiiiwiimiiiwloiii 
fOIy offer Gonfidornblo diiGcultics in dingnosis, and 
(licir careful study 13 of mucK importance. The fol- 
lowing is ttu instance : — ■ 

October, 1858.— H. P., a »i:itc ngt-d 38, came 
under my core in tlic liospitnl, oti nccount of severe 
soffcriuj; iu both ankles. It ap])Cttred from the history 
of the cnsc, thnt hi» father hnd been greatly offliotod 
irith some joint di-wa-ic, to rach an extent ns to oauso 
him to be bMridden for sixteen years ; it was con- 
sidered to bo rhcuniatism. The patient, when fifteen 
years of age, had an attack of what appeared to be 
rhoumntio fever, dfccting tlie wrist and other joints 
of the upper eztromitics; seven years afterwards, he 
had 11 second of similar cJianwter, but implicating the 
lower cxtivmitics rIso. From this time to his admi-tsioD, 
hehitd FufTercd at four or fivodifforent periods, tlic dis- 
ease genontUy assuming a chronic form, and rendering 
hitn helpless for many months. IIq cannot remember 
that the ball of Uio great too was ever implicated. Ily 
occupation }io is a cellarman, and is exposed to cold 
and damp ; he takes on an average each day, at teast 
four pints of pale ale nr other malt li<juor, and some- 
times a connderabic amount of wine. On admisdoa, 
three weeks after the commencement of tlie attack, 
both ankles wore painful and tender, but not swollen 
or red ; he u-as unablo to flex them, and the least 
attempt to do so was accompanied nnth mucli pain; 
polso 73 ; toogno slightly furred luid no thirst ; appo* 
tito modenttc; bovcU regular; do perspirations; the 



EXCETTIONiL CASES. 



» 



pain ID the joints somewhat increased at ui);hL The 
urioo scanty, ep. gr. 10-30, ginng rise to sonic crystal- 
lioo deposit of urio acid tm standing; uo albumen 
piesont. 

Ab ttiere vas som« doubt as to the real nature of 
t]ie disease aboat two otmces of blood vcro taken 
from tbo arm, and the scram exhibited the presence 
of a moderate amount of orifl add when treated 
by the thread experiment detailed in a subeoquoot 
chapter. 

The patient tras put upon middle diet, and a few 
grains of iodide of potassium ordered; but after foor 
days his condition remained the same, with the excep- 
tion of a slight alienation of the pain in the joints, 
probably due to the perfect rest and regulated tcmpcra- 
tora enjoined. It being i»uud upon iiiqnir\-, that bo 
bud usually taken pale ab in prvferciico to poit«r, 
oonsidcriug it better adapted to hid disease, and as 
he thought he foU more pain in his joints after 
taking stout, and, moreover, as tlio examination of tho 
blood had shown tlie existcnoo of an abnnnnal quantity 
of luic acid, I deemed it adviitablp, in order to orrirc 
at a oorreet diagnosis, to see the iufluooco of a change 
of diet upon the patient. For this puipo«o, as his 
Kppetiie was good, tho extra full diet uf the hoc4])itAl 
was allowed, with tho addition of two jnnts of porter, 
I being omitted. For tlie next four days all 
on satis&otorily, but on the fifth he oomphiincd 
of severe pain, first in the right and then in tlio left 
aoklo, whicli soon became swollen and red, and two 



ICUTE GOCT. 



dajTS afterwunU pitttd frtvly on pressure, (md gare 
rise to deaquamatioii of the euticlf ; tlio tongue vraa 
Ainvd, pulso al)ovo JOO, but no markt-d thirst. The 
porter and meat were then discontiuucd, oiid a draught 
coutfuniiig half a draclim of colcbicum vino iu cam- 
plior mixture, odmioistcred tlirec times a duy. Within 
fortj'-eight boors, the anldcSMrero gu-atly rihovwl, and 
in R few daj'ii quite frcti from swelling or redness, and 
altogether in u much hcultJuer statu than sinue the 
commencement of the attack ; the colchicum did not 
produce either nausea or loosonoes of the bowel*. 

Why the great toes escaped in this en^o it is difiioult 
to determine. May not the acute rheimiatism iu early 
life have left a certain amount of alteration in the 
lai^ joints, predisposing them to become affooted by 
the gouty ])oisou ? Wo know that after accidents tho 
weakened piirtd arc moru susec-ptible of it» iiiflucuco. 

In this case no deposits of gouty matter could bo 
discoTCrcd) but the lirst phalungeal joint of tho right 
little finger was flexed and almost anchylosod, whether 
or not hy the deposition of uriit« of lioda in and around 
tho joiut, it is imposublo to decide ; Iiowcrcr, the 
charnctcr of tlio inflammation, the eoudition of the 
blood, the influence of diet, and tho striking effect of 
colchicum upon Uio disease, h&ve no doubt that the 
caso was one of true gout ; and there can be no reason 
why a patient, who was in early lifo subject to rheu- 
matic fc^Tr, should not acquire in after years tlio 
gouty diatliesis. Several instances havo recently 
occurred iu my practice uf tho abscocc of great toe 



Smt^LATIA'C ACCTE RUEUHATIStf. 



3D 



mort uncquivucal gout, and I 
that they arc found mora fre- 
quently in tbc upjwr classes &f Eocicty, among those 
who i&hcrit gout, but have not indulged frocly in the 
ploanrcs of the table. OceoaonoUy wc find eufficient 
nwWBS for tlio exemption of the ractatanto-phalongcal 
joint, which wo sluill again havo an opportunity of 
discQflsing. 

We have said that gout in its early attaclu ordi- 
narily selects ono, or at mo^ only a fcv joints, and 
that tho smaller articulations are more particularly 
fixed upon ; exceptiona to this law are now and then 
met with, in which not only are the larger joints 
implicated, but the number affected increased, and 
there is often much difficult, at least at Gnt, in 
making a correct diagnosis as thoy cloedy rvninblo 
of acuto rhcumatiBm ; a very remarkable in- 
lOc of tluA form of acato gcncnd gout came oodor 
my care a few yean since, in which tlio suli^uent 
phoooouna left iiu doubt of its true nature. 

December, 18a3.— C. F., a man aged 35, was 
brought to the hoqntoL under the following circum- 
6tance«. He hod on tlio prcrious day been struck in 
the inlru-axiUary region by tlie shaft of a cart, which 
Iiad knocked him down and fractured one or more of 
tho left ribs. Ho was admitted into a surgical ward, 
and as tltero was ovidcuoo of some small omaunt of 
tramnatic pleurii^y, he was ordered to be cupped orer 
the diest, and to take threo-gnun dofiOS of blue pill 
and half a grain of opium every three hours. In tho 



« 



jLCDTb gout. 



ereniiig he Ml pnin in tbo k>ft elbow-joint, and 
darmir the night tho finRors of the samo hand becnme 
red and swollon, in addition to which the soles of 
tiie feot ftnd right knee urere ioTolvcd. As the case 
asBumcd more of a medical than snrgical character, 
the pntiont was next day (two daj-s after the injurj-) 
transferred to one of my words, when his condition 
was a follows ; 

Countcnanco palo and snllow; pulso 108, rather 
Email, but tiard ; skin hot and gonicwhat moist, tougua 
furred, ginns red imd nwoUon, and breath mercurial ; 
much thirrt and loss of appetite. Tlio joints aifectcd 
wore the hit ivri:«t, band, and elbow, which were hot, 
red, sod swollen, likcwiw tlio right knee uud ankle, 
and UtUo too of the left foot. A frictioQ soaiid vm 
beard from the middle of the left bock of the dicst 
round to the axilla. 

Tlio next day moat of the inflamed joints pitted dis- 
tbotly on presiure, and the middle joint of the right 
index finger was much swollen, the circumferenoo 
being at least twice that of any other; the skin nl-so 
was very hot and red, and the whole 6nger oxqui- 
ffltoly tender and painful. On tbo following day tho 
condition of tlio patient was mneli tho same. Up to 
tills time the patient had been looked upon as suffering 
from acute rbenmatisa, and the treatment had been 
snch as is usually adopted for this disease, but I now 
suqiected that my first diagnosis was faulty, and that 
tbo case was one of genuine acute gout ; my reasons 
were as follows — f\'nt, tbo blood drawn by cupping 



SlHULATtllO ACUTE BHECUATISU. 



41 



: Gie cheet was found on cxamtnataoa to bo ridi 
in orio acid ; t^cotidfy, tbo clinmctvr of the inflsmma- 
tioa vaa sucli as neually ooours in trw gout and raivly 
in rhcomatisin, the more tntpgrtant points hciag the 
Bhining appearsDce of the inflamed ekia and the sub- 
seqaent pitting on prcssuK ; f/tintty, the ^t of the 
patient being so readily afit-ctcd hy mercurials — an 
oocarrenoe by no means uncommon in goat, but rare 
in rheumatiBm ; and /astly, I iras assured that the 
patient vas labouring under acute gout, from the 
future progTC«a of the caw. In the oouik of a few 
days the svelling of tbo right index finger ioereaeed 
to such an extent as to present tho appearance of 
intcnitc dfstondon, and to give rise to llnotwttion ; at 
the same time tho other joints verts much relicrcd, 
aod the febrile disturbonoo had abated under the in- 
floenoo of tho colchicam adnuni«tcrod. Shortly aAer- 
wards, on puncturing tho distendnl skin of the finger, 
a milky fluid exuded, which, under tho microscope, 
■was fouid to owe its opacity to innumerable crystals 
of urate of soda, in tbo form of Tcry fine needlce 
(Plato 5, fig. 3). On making Airthcr inquiries into 
tho history of the ease, I aeocrtaiucd that this -was 
not tlio first attack of joint nfloctton ho hod cxpc- 
rienccd, for nbout fifteen months previously ho had 
laboured under some inflommatioa of the foot, vitlt 
the I'tuirnctcrs of ordinarj- gout In tlio oonrse of a 
few weeks t)io nature of the case was still more 
eleorly oetaUislicd, from the fact that a small deposit 
of nmte of soda oocorrcd in tlie helix of one ear ; and 



V 



43 



ACUTE OOUT. 



I &Mt period, HOT about : 



n yean*, chfllle stones 
hsTS fixrmcd in difTorCDt part-t, aud gouty sj-mptoms 
have from time to time exliilittvd themselves in tlicir 
ordinarj' type, in the great toe and elsewhere. The 
patient was a painter hy trade, had drank about a 
quart of porter each day, and appears to inherit gout 
from the mother's side : two of hi.i brothera have anoo 
been my patients, BuiTcring from the same diBeasc. 

Many cases of acute general gout, more or less allied 
to the one just quoted, have been described and re- 
garded as attacks of acute rheumatism. I am inclined 
to think tho following, which 'm dossed us one of ncuto 
rbcumatiim dcvdojwd during an attituk of acute gout, 
is an i-xamplo uf this fact ; it is relutcd by Mr. Spcnoer 
AVells in his interesting work on this subject : — 
"A gentleman about forty yours of aye, descended 
from gouty purcnti, and accu»totiicd to indulge rather 
freely in the plea.'<urc-H of the table, about five ycats 
ago had a slight attack of gout under the ball of tlio 
right great toe. This soon went off, but at intcn'ab of 
three or four mouths similai- attadts had recurred, 
their severity and frequency both being on the increase. 
Ono evening he felt that an attack was threatening, 
but he attended late in the IIouso of Commons, and, 
as tho pain was increasing, ho thought a day's oscr- 
eifle would probably ward off tho attack, as ho hod 
found it do so before. Accordingly, on leaving the 
House, he pi'jstod all night between seventy and 
eighty miles to have a day with his hounds Ho 
arrived but ju.'st in time to e^uip for the lield, and bad 



J 



BlUCLATrKO ACUTK RHEUMATISIL 



43 



IT two eliort runs and a ren- long oue, in the midst 

of tlio run on a a^d dajr. He bad to rido fiiW'D miles 

so ■ tired horse, <m rctarning, and wlieu bo rouchod 

bDOko had to be lifted from the saddle und carried to 

bid. He took liot brandy and water, but a bovoto 

ligor evne on, ai>d a general attack of acute rheuma* 

Umi wt in CIO tbc folluwint; day. It was so severe that 

ttu) gvaty iuflammatioQ af tbo foot was disregarded, 

■ttntwm \mng giroD to tho state of the hetut and 

|(Benl oonditiou. In about u fortnight he ivas ctm- 

nlcflocnt, ao fiir US the rbcumutif ni was concomod, but 

tiw goufy action continued in tJto foot, and cHd not 

£nppenr until a fw ivam of colchicum had been 

gmm." Anotbcr cow ftom tho same author, and 

ooBsidered to be likowiw one of acute rheumatism in 

a pefBOD affMti'd with ohrotuc gout, is as follows : "X 

gntlcmAn aflbctod with chronic gout, having 0(xn> 

lidamblo deposits of litliatea in the lingers and around 

th* ankki, and being subject to copious urinary de- 

fBtUt of var^'ing composition, passed some time in 

liolta to obtain the advaata^ expected fix>m living 

in a warm climate. After a von- hot day he remained 

m a boat in the harbour, fishing, for some boors, on a 

Bxioalight evening. Ho had bcui pcrapiring freely in 

the itflrraoon, and was lightly dressed. He felt rather 

diilly before be went bomc, hud a svrcrc ehirering fit 

m tho oigbt, and was confined to his bed for twclre 

dsjt with a smart attack of acute rheumatism aficoting 

tbo knoes, shooldcrs, and loins, bat not any of Uio 

juiati which had prcvionsJy been afiected by gout." 



ACUTE GOUT. 



Thnt many cosos of ocuto ^ut hsn beon. Tni'trVt" 
for itcutc rlicuni»luiii, I ilo not Juubt. and on the COB* 
tran-, Unit rtuino fuw c^u^s of ucuto rluiiunatism have 
been rcgunlud as of n gouty nature, I am no Ices 
certain; I may refer to tho oft-quotcil cow Ly Dr. 
Haygurth, in wliicli gout is supposed to haro boes 
transferred from tlie oxtruinltiuii to tho Loart, as as 
oxampic of tho Utter error. 

The early attncki^ of gout aro not usually followed 
by any very appreciable evil oonsequfiQCca, and as ono 
of the effects of a serere paroxysm ia to rid the blood 
of the impurities which had probably been lurking 
there ibr some length of time, it is not uncommon to 
lioor patients express themselves as even benetitwl by 
tho ocourrcnee of the gouty fit. Gout, on this account, 
wns formerly looked upon m a salutary diwose, and 
ono capable of removing all others ; but tbo error of 
tliU opinion can bo now rnajily domoustrated, and wc 
shall bo able to show that every attack is attended 
with permanent local misobicf, ^hich, though slight 
at first, may, by frequent repetition, bo sufficient to 
induce serious inconrenioncc. Tins opinion as to the 
advaDtagOfl of gout is now fast weaiing out, ercn 
amongst the public ; intelligent pbydeions haro long 
exposed it3 &lIaoy, and have combated it, as shown by 
the following extracts fiom neberdeo's Commeotariea, 
and Costc's Traits pratique de la Goutte. Heberden'a 
remarks are to thui effect, that although Home patients 
oongratolatc themselves upon the completion of their 
wishce, and during tho honeymoon of tho first fit of 




lOSCHIEVOUS COSSEQCENCESL 

dream of nothing but perfect hcaltli and linppi- 
MK, and porsondo Uiciaj<ctrc« thut they arc much tbo 
bitter fiir it, stall thia is the exception rather than tlie 
nie; tor bo itabM that ho had often soen gout arising 
(isriiig the progross of other dlvntcs without giving 
idicf. And tliat the number of cases in which it has 
{Rudocod increased Qilwhicf n-as double that in which 
it had bofricDdnl the cmistitution. It i^i true thitt 
flftv disorden will at times he su-xpcnded upon an 
ritadc of gout as npon tho accoesion of other acuta 
diMaacs, bat at other times no such result fallows. 
Bcbcrden states that if gout return but seldom it may 
do but little harm ; but so may cpilt^p^y occur onoo a 
y«r, yet the patient lire to u good old age. 

IL Co«tv writes to thia effect :— " A jiopular cnor, 
irideh I wish to expose in a few wordi!, is this proju- 
div, which has already lasted more than two thonssiid 
jmitt and which has reached eroa the thrones of 
^tiaotM, where the disease conunonly shows itself, riz., 
^^pat goat prolongs life (que la ffoutte prolonge h vie), 
^Bhis vnot" aays he, " has taken the surest method 
^^f introdiutDg itself, by making flattering promises, by 
I pmntadtBg its victims that thcrt- is a singular advau> 
ta^ in haTing gout, and that the mulady drives away 
■U other tmSs, and that it ensures long life to those 
vbtim it attnckfi." 

It occasionally happens that a patient fails for a 
loBg period to get rid of the ill cfieots of an attack of 
acata gout, for tto offcctwl pixrts may remain very 
Uodor fbr a loi^ period of time, although no appre- 



ACFTB GOUT. 



ciable structural mUchiof hns taken pinco ; and some- 
times thero is a considerable tcmlcnoy to edenm, morv 
especially if the fit bus boon "f lung duration. A caso 
occurred in my pmcticc a few years since, bcnring 
forcibly upon lliis jraint. A gentleman enjoying good 
licalth, witli the exccirtion of occasional attacks of gout, 
consulted me on account of some swelling of the foct 
and ankles, remnants of tbe last fit of tbo disease. Up 
to the period of the last attack he bad been accustomed 
to apply to bis usual medical adviser, and was gcno* 
rally restored to bwilth in about ten days or a fortnight, 
but in the Inst attack ho bad been persuaded to pat 
himself under the treatment «f a homreopathic prac- 
titioner, and hod complied strictly with his injunctions 
regarding botb medicine and regimen. At the end of 
the fortnight instead of findiug himself well, as had 
formerly been the ctuic, the disease was still present in 
its full intensity; be was, however comforted by the 
oHarancc that, although tbo cure might bo dow, yet 
it would bo tho more ooniplefe, nnd Uiu* he continued 
to bear hia sufferings for seven weeks, until tho affcG- 
fioQ had fairly worn itself out ; but it bad left, as 
sequela, considerable tenderness of tho structures 
which hod been inflamed, and well-marked edema, 
symptoms for wbidi be was desirous of obtaining my 
adviec. On examining tlic urine, it was found free 
from eren a trace of albumen, and the only causo 
which could bo assigned for tbe swelling was great 
weakness of the blood vesseb, the result of the pro* 
longed inflammatiop. Treatment adapted to remove 



UISCHlEVOirS CONSEQUEKCKS. 



V 



any remains of gout, together with the uso of tlio 
daido stooldng, proved sufficient for the cure. Tliis 
ctw is a good illiuctnitioii of the fact that, c^tn with 
gremt ooru u rog&rda diet aad regimen, gout may 
frore oxtrenwly tcdiou*, and wo shall be able to prov« 
that sadi dumtiun i» nttfudod with the productina of 
MTiuuft mischief, and Hliould be curtailed whon poeetblo 
hy tbe Application of appropriate retncdinl mcamrcs; 
thote who bare had many opportunities of witnessing 
the frognm of gout will not, I beliere, be ioclincd to 
■poe with Cullen'a aphorism: "The common practice 
df committing tbo person to patience and tlannol alone 
a ntiiblishcd on the best fuundatiun." 

Although the earlier attacks of ^ut arc usually 
■oattcnded with any great amount of subycqucnt in- 
oaOTenicnice, this is not invariably the case, as I 
htn known the formation of chalk-stones occur very 
riMRtly after the commenccmGnt of the diitpiise. and, 
vitbin n period of two or thrvo years, incrcoso to 
mdi an extent ns entirely to cripple the patient. 
Sndi an oocurrvnec, Iwwcvcr, forms tJio exception, and 
not the role, in tlio ptragreai of gout, for, on the 
other hand, many eoacfl haro come before me in 
pracdoe, tn whioh the patients bavo sufimd, more or 
low, for forty or fifty years, without pcrocptililo incon- 
vcttieooo. 

A«o(o gout, even in its first attack, and apparently 
with but slight local tn6ammatio&, will occasionally 
atoM pomuiuot stifEbMs, or complete anchylosis, and 
thia may occur with Tciy little accompanying enlarge- 



49 



ACUTE GOUT, 



ment, thougli attended with serious obangcs in the 
deep Etmctures of tlie joint. 

A recent coi^c well exemplifies tliis fact:— J. P., a 
male patient, iifty-sii j-eara of age, by occupation u 
fishmongor, Iiaving oo known hereditarj' prcdL>i[)osi- 
tion to gout, has bovn uncustomed to driuk pretty 
freely of porter and gin, as muoli ns four pint:] of tlio 
former, and liulf-ii-pint of the luttcr daily, eomctimos 
m<mi. About five or six years »inoo, when going up- 
sburs with ii henry weight, his foot slipped from ooo 
stair to the next, but hu did not consider that ho had 
Iiurt himself; about two or Uirco days after, the ball 
of the great too became very painful, red, swollen, 
and hot, and the attack lasted from three weoks to a 
month, no ticntmont being adopted except rest iu 
bed ; sinco tliat period ho has occasionally had poius 
in tlii« joint, but liiw never been again laid up with 
it. Although ttiere has been but one dbtinct attack, 
tlie joint is completely aiichylosed. About eleven 
months ago he had pain and swoUiag of the right 
unklo, and also of some of tlio joints of the Gngen, 
several of which were left partially anchylosed. The 
attack for which he come under my care, and which 
iras apparently caused by an operation for htemo- 
rrhoidra, commcncod about t«n days previously, with 
pain in the right ankle and two of the fingers of the 
left liand ; two days alW tho pain loft the right and 
attttokod tho left ankle, and subsoqucutly the luico on 
the same side. At tho time ho wus lirst seen, there 
was considerable swcUinjj of tho first ph&hutgcol joint 



UI8CHIET0U8 CO:!8£QU£Ki:C8. 



IS 



the middle finger, and pain vut occa^ioni'd on 
attempting to mora it; tht! ankles wvrc ouly slightly 
swollon, but tender on prp»«urtf. One of the pliulitn- 
;j|Ba1 jointo implicated during the lft9t attack wua 
Ibrnd <wolleit and »tiff, and oppoarcd to be partially 
iti»el^(»cd. 

Another imEtanoe has come under my nodoe, of a 
gentleman who, although free &om all appcaraaoc of 
deposits, hafl OMnplt-ti:' rigidity of the lull of one i^itt 
toe, the result of a few 6to of acute gout ; on the 
other hand, patiente may hav<> repeated atta«kis and 
yet no rcn* pcrcL'ptihIe rigtdit>' ensue, although wc , 
ah«U find the stmctoreo of the joint considerably 
«8botod. 

Within the last two yean, since the puhlieatioii of 
the first edition of the present work, I h&ve hnd the 
opportunity of examining the condition of the great 
tflos in two instances of anchylosis, which will bo 
found dcecribed and dclin<?at«d in Chapter YII. 

BefoR! conclndiog this chapter, i cannot refrain 
from giring the paaBugo firom Sydenhun,' although 
often hfforc quoted by nnthon*, in whitJi he dmcriboft 
the goaty fit ; tlie dtvcnption ia so graphic and 
vivid, the result of acute and screrc poisonal 
Huffcriug: — 

" Towards the end of Janaary or the beginning of 
Febnuiy, suddenly and without any pTenumitory 
feelings, the disease brooks out. Its only forerunner 



I'raBlbiifW(kUoaufS]ril«n^in'iiVorli«, bjr Dr. H. 0. lAthua. 

* 




i 



s» 



ACUTE OODT. 



is indigostba and crudity of tho Etomocli, of irhich 
[tnticiit labours Rome weeks before. Bin bud}' tw 
evfolliii, lienry, and windy — B)inptoin8 wbich ioi 
until the fit breiilts out. This is iirecvded a few da; 
by torpor iind u f(.i'liii]^ uf flatus uloiig tbu Ivgs and 
thtgliA. ltc»ido.s tliis, t\iv.Tv is a »j>iL$iuodio uRcctioD, 
wbitst the day bcforo tlio fit tlio 8pi«tito is unnaturally 
hearty. The victim govs to bed and flc<:y» in good 
liealtb. About two o'clock in th« luoming lie is 
Bwakoned by a severe pain in the grout toe; mora 
rarely in the heel, ankle, or instep. This pain is like 
that of a dislocation, and yet the partA feel as if oold 
vator were poured over them, Tlien follow chills and | 
Hbivors, aod a little fever. The pain, wliiuli was at 
first moderate, bocomos more intcnio. With tta ' 
iaUfosaty the diilU and ^hivcni increase. After a time 
tliis oomcs to iU height, accommodating it^f to Uu) I 
bone* and ligaments of the tamuji and nietatarsuA. 
Xow it is a %-ioleut strctehiiif; and tearing of tlic ligar^| 
ments — now it is a gnawing pain, and now a pressure ~ 
and tightening. So cxquL^te and lively meanwhile is 
the feeling of the part affected, that it cannot hear 
the weight of tbo bedclothes nor the jar of a person 
walking in the ronm. The niglit is ptifisod in torture, 
Bleeplessncits, tunking of the part affected, and per- 
petual cliJHigo of posture ! the tossing about of the body 
being ox incessant tw tbc pain of the tortured joint, 
being worse iu< the (it comi-a i^n. Jioii<.e the vain vJTort;^ 
by ebangc of posture, both in the body iand tbo limb 
afibcted, to obtain on abatoment of the pun. Tliis 




HVDeNIIAH'8 l>KSCKIITIUN. 



n 



only towanls tbo mamiiig uf the next day, 
«ueh time bdiiK neccttcary for tlm moilurute digeetioti 
of tlio pcccaiit innthT. The- puticnt has a suddeu and 
slight n»^>ito, which \w diliwly attribuU'S to th« lust 
dian)^ of pneitioD. A guntio [lerNpiriition is iiiioccoded 
by sleep. He mlcM fiwi- fr»ni jkiiii and findii t)i« 
part recently aw«tll«n. Up to thin tinie, the ouly risible 
swi-lling has been that of t1i» ^'eins of the atfeutotl 
joiiil. Next day (perhaps for the next two or tliree 
days), if th« generation of the goaty matter have been 
Abundant, the part affected is painful, p'ttint; vrorKe 
towards cvi'iiin); and bctti-r towurd* mnmtiig. A fi-w 
days aflvr, the other foot swells, and sutTor^ the fame 
painx. The jtain in the foot «L-cuiid attacked roKtilatcs 
the Atatc of the one liret attiti^i.-d. Ilie more it is 
violont in the one, the mon> perfect isi the abateinent 
of suffering and Uiit rctimi of rtniigtli iu the oth«r. 
Kcvcrlhck**, it brings on the same affliction here as 
it bad brought »n in tho other foot, and tliat the same 
in inteastly ami iluriilion. S(>iu<<tinies, during tlie 
first davit uf the <lL'<eiu«o, the pc<«ant matter is m 
exuberant, that one foot is insuHicient for its discharge. 
It then attacks both, and that with equal violence. 
Qenvratly. however, )t take's the feot in succviwiiiu. 
After it ha» attacked each foot tbti lits become im> 
gular. butli afi to tba tinw of their noiiceHOD and 
duntion. One thing, however, in constant — tlio pain 
ioervutHM nt niglit and rvmitic in tlie morning. Now a 
ti^os of It-mcr fits liki; these c>itL->litiitefl a true atluck 
tff gout— long or short, aooordiiig to tlio a^ i>f the 

a 3 



62 



ACCTK GOUT. 



pittienl. Ti) xiipjioMv tliiit lui attack two or tltr 
moiitliK ill Unij^li is all oub tit is emmeHUH. Ic 
ntthcr ft scries of minor Rt«. Of these tho luttiT 
milder th»ii llu< roniior, no Unit the peccant matt 
is (lisubnriicd liy ilegrotw, and recoverv ftillowH, In ' 
Arung conKtittitioiiH, when the previous attacks hiiTi> 
bct'ii fi'w, a fortnight is the length of an attack. With 
age Biid in)]>airod haliita gout may last two months. 
With rcry iidvancod uge, aiid in constitutions nrry 
much broken dowti by prcvinua gout, tho disease will 
hung on till thu sunimur is far advanced. For the first 
fourteen chiys thi^ uiiiie is high-coluurod, has a red 
eediaent, and is liiadL-d with gruvi^I. Its amount is 
leiH than a third of what the patient dnnkit. Diiritig 
the same period the "bowels are confined. Want of 
appetite, general cliills towards evening, IteavinoM, 
and a troublesome feeling at the parts affwted, attend 
the fit throughout. As the lit goes off, the foot itchra 
intolerably, most iK^twi'cn the tucs ; the cuticle scales 
off, and the feet dew^uiuniite, n* if veuonied. The 
diw-aw! being disposed i>f, the vigi>iir and uppetite of 
the patient return, and thiit in pi-»portion to the 
violence of the last fita. In the same proportion the 
next fit either comes on or kpep« off. Where one 
attack lia-« been xlmrp, the next will tuko place tlint 
time next yi'ar — not earlier." 



CHBOXIC OOUT. 



« 



CilAPTEIi in. 

Cvune Oout:— NOT * (outinr muu n tmi icctb tmonoK 
— tamnamon m—ovutmn»jkK trunwta— ugmtMKM or 
ttkmtDu ttomti* n cHwiiija wvt— Rttcas of sni a»- 
C1U4I' uiuLE-noiKi 0* TCraioMtii DwwiT* — mtia ■iiin»- 

— tiTvinoK or— vroM iau— onui oi««iii tn NAa««*i* — 

HUUKD JOIlTtI — MltHM HVU^ — UMIIM HUOn DsmMltl — 

ILLUMftiTKB cjtBKS— a>rrr Annwu— >m. kmi^i HMiitf- 
no* or— ctwnrKtTiKn lupuia i« t«k roaninvK ur ixtu* 
■tTB oBAfcK-uKx aaioHia — nvumut'i tMCMrriMt ur 
CBUNio Mirt. 

Ttii: boundnr)' lino bctwcn anito and chronic gout 
[is eoinpletolyatbittar)'; ncvcrtWli«s ""fhen the disease 
I halt mude much inroad upon the coDstitution, and its 
attacks have become fiwiucnt, the afftiction assumes a 
foriD to which th« Iprm Chmuic Gout may properly 
llx) applied, and thgugh it may not causo snch uxcru- 
tinj^ suffmn^ ajt the mon> raix! and intPitsG x'isitutious 
Ftiii' iicato disease, still, by its protracted duration, it 
is apt to induce a depraved state of the whoh) ejittcui, 
and by leading to distordun taii rigidity of tlie j<iintii, 
the fonuatiou of chuIk-t<toni.'!< antl othiT H^^wlie, em- 
bitter the life of the sufferer to sucli «« extent that, 
BS Hebcrdeo forcibly remarks, — "Tlint gout canscs 
premature death, when all ilitf oomftirts of life are 
destroyed, and the physical povrcn cither insensibly 




Si 



CHRONIC GO ITT, 



undorminod or suddenly crushed by an attack of 
parolj'sis or flpoploxy, ahnuld hardly he reckoned 
among the nusfortunes attending the disease." It 
most not. however, he assumed Ihiit f^ut ulwnys leads 
to 8uch torriblc result*, for, whon tho constitution has 
been originidly good, when little or no lieroditary prts 
dispositioQ ensts, and no great dopresKuig cause or 
itujiropcr treatment has subsequently induced a sbat* 
terod condition of the system, instead of the attacks 
increasing in ficquency, they may become more and more 
rare, and even after a lenj^ened period, little injury , 
may have resulted from them. A genttoman, who died , 
a few years since, under my eare, at the advanced nge of 
eighty-four, liud suffiTod from g»ut fur mnro than half | 
a century, but the wppLT cxtrcinilies hud been iiln-ays , 
exempt : no cliidk rtoncs, stifTueiiS, or defonnities wore ^M 
risible ; and during tbo latti-r part of his life the fitfl " 
wore slight, and at long intervals. Many other casea ' 
in which gout had lasted from thir^ to forty years, 
without any appreoiable amount of injury rcmlting, 
have come under my obscn-ation in practiee. 

In tbo other and less favourable clas." of eases, the 
disenso gradually becomes more frequent and irregular 
in its viKitutions ; instead of occurring annually, or 
half-yearly, only a month or two may elapse between 
the attacks, and as these are generally more prolonged 
than in ocuto gout, a fresh fit will frequently ensue 
before the subsidt-nce of tlie preceding one, and thaa 
the ptttietil may be scarcely free, except during a few 
of tlio summer monttu. Thu joints arc usually swoUea 





I 



I 



I 



DBSCRTFTIOK OF 

effusions into the bareie at cspsuled, and likevise 
stifieoed ; (hi-rr may he no rodne^ or increased lieat, 
eompanktiv«I)- little pain, and an absence of febrile 
oxoitoin«ot, exoopt porliaps a little at ni^t, aocom- 
ponying the increased patn which then gvncrally occurs. 
Althot^h there may he no fever, still other 6>-mptoms, 
whiob o[t«n prcocdo and oocompany attfidcH uf acuto 
goat, arc apt to be proscnt in an oxa^i;enit<^<l dogn-o, 
auoh OS miuoular and ncr^-ous poitu (often regarded u 
rhfumatio), crwnpeH dyxpoptda in all it« vnrietiw, 
evioocd by iwidit}', heartburn, pyroeiR, flatulenoe^ 
weight and pain after food, palpitation of the heart, 
conKtijiation, deficient or depraved secretioD of bile, 
lowness of tipirits, and so forth, leading in time to 
great impairment of the general health, sallownen of 
the complexion, and eroadation. The urine, at fint 
of a high oaloor and Uirowing down copious sediments 
uf urates oa cooUng, now becomoa pale, remains bright, 
is more copious, and, tf deposits occur, it is only after 
a severe exaoerbadon ; a traoc of albumen is frc<iucntly 
present, especially when the joints aro much io&amed 
and febrile disttirbanoe exists. 

Sometimes chronic gout is confined to ooc or two 
joinls, MHsetimcs naau)rou« articulations arc involved ; 
ooeuMDally it leaves tliu juintA and attack)) other and 
Booro impoiiont stmetnrea. When limited to a fow 
joints the diwasc is likely to produce permanent local 
mischief, but when it aRsomee the erratic form, tlio 
aerioufl ciTccts deactibed under Misplaced and lletro* 
oedi'ut Oouti are prono to ooour. 




H 



CHHOSR: UOITT. 



Chronic gout Bcldom oontmneB in one localitj- for 
any IcngtU of time without givmg rise to serious und 
pcrmuneat change of structuTR.coiisisting either in the 
production of partial or complete anchylusiit of the 
joints, or the formation of tho so-eallod oh sllc- stones, 
cither around the articulations, or in other part< of Uie 
body. 

Bcfurc di>scribing these modifications, it will bo well 
to allude to the nature nnd composition of the ehiUk- 
liko deposits, us their occurrence is completely patho- 
gnomonic of the disease, being never found in any other 
ntaUdy than gonuine gout. They arc railed oliallc- 
stoncs, and lionco the varietj' of the diseiiao in whicli 
they aru seen is sometimes designated chalk-gout ; 
other Dames have been occasionally applied to them — 
ns tophi, a word derived from the Hebrew, and implying 
euncrction. The term chalk-stone is, strictly ^(icakiiif!. 
erroneous ; it was first usikI whi-n tho (lt'posit<;d mutter 
was siq>p08«d to consist uf chalk, but wc now know 
that no such ingredient exists in it« conipo-sition, and 
that when pure it may be devoid of lime in any form. 
Although the older phyedoians were entirely Ignorant 
of tho true nature of this chalk-like matter, their ideas 
as to ite pathological relatiims were not so erroneous, 
as has been generally supposed; for the ancient 
writers, including Sydenham and all other authors 
belonging to the school of humoral pathology, consi- 
dered the matter to ho undiizested gouty matter, 
thrown out around the joints, and afterwards becoming 
hardened. 



CHAitACT>:B OF rHALK-I.IKE DRPaSim 



17 



The oonsistcncc of these diiponits raritis exceedingly ; 
BometimeH the>- nrc mft, nt othirr times as hunl as chalk 
ibeif ; in order to do]n»a*tniU- tfacir true cbnmcter, we 
will exiunino them can-fully in both conditions. 

A little white 8pot is often ol>sen-od iiiHin Uio helix 
of thv 0UT8 of patients soffiering from ohrwuc gout, and 
if such h«8 been recently foroMxl, it gives rise, nrlu-n 
puit<>turt)d with the point of a lancet, to the exit of it 
Ht^mifluid cream-like exudation. Thia matter, when 
coTered with a film of gUia, aod pW«d undor tho 
mitinMco])c, exhibits the nppoiinuiM ebowa in Plate 5, 
Sg. 3, And connsts of ■ clew fluid containing a great 
number of ncieular erystala, exceedingly smsU, and re- 
quiring considcrablo mag- 
nifying power, and good 
definition to show them 
distinctly ; with tlicsc 
crystals a few blood discs 
are frequently mixed, 
ansiiig from the slight 
injury to tlie «kin. If a 
little of the white exuda- 
tion be hcntcd with a few 
drops of dilute nitric add 
upon ft porcelain dish, and when fdmost dry ex- 
poNod to the TUjKiiir of ommoDia, a beaataful purple 

• FI(. 7. The »pptttf»w« |iw«ta<«J Vy > dt«p tf tbt enMo-lii* tuld 
obtafatd b; pniLi!liiri>( & nouiUj formed nnU af Md* ikpsdt. Tint 
is Iht ibawidt *M obMiDnl fhun Uw famckb tt » jaUtal whoM an 
i* dnoribfd in ihe ptMcnt clupler. Lisau mieniiyiiic po*I« SSO, 

p«luUMlficbk 




I'ii- 7.' 



n 



CHRONIC OOUT. 



colour is prodoood from tho fonnation of miirexido, 
ptirpuTiitv uf ommonin ; if, od Uio uther Imnd, it 
dried snd inanciriU'd, u littlo ash is left, alknlino, audi 
exhibttiiig all tho rciu;tionH of i>ndtt. Under iiolimxcdj 
light, tlio appfurmicc pn'.'«i'iitc(l reswnblca that secii in I 
fig. 7. Thi' whiti- miitlvr is soluble to some exloot ia'j 
hot water, and its solution on cooling or eraporatioa^ 
duposit« iiix-dto-liko cryHtaU of urate of iwda, osoally 
arranged in bolls nr tiifbi (Plate 5, fig. 4). 

If a concretion in a semi-aoUd t'oudition Iw exa- 
mined, tho fame appearance is exhibited, exci>pt that 
the orystal§ are more aggregated together in massoa 
Bometime» difiictdt to soparnto from ouch otLcr, but 
this can bo effected by putting a drop of water upoo 
the cdide, and then ueing a little pressure ixitL tho 
tliin upper glass. 

These white dcpoflit« arc thus shown to conast 
essentially, often cutirclyi of urate of soda, but, when 
I'mlx^dcd and hurdoncd in any tissuo, animal and 
curlliy matters may Imh^our' intimately unit^-d with 
tbcni, these can be separated by treating the mass 
with hot water, and dissolving out the urat« of soda. 
A small portion of the uric acid is now and tlien found 
in eombtoation witli Home potash or limo ezistiDg in 
th« tianiea, in the form of uriite.i of them bascB, but 
the amount of sucli f^olts h generally intiiguifioant. 

It is probable that when fimt thronn out the matter 
jonning the depotitA is in the form of a limpid Huid, 
bat, being rich in urate of soda, rapidly assumes a 
milky appearanoe from the crj'stallisation of that salt ; 



COMTOSITIOH OF OOUTT DEPOSITS. SS 

oe waten* pirtian is slowly ubsarbod, and the conoro* 
tiuns gradually luud<ia uotU they twquiro a firm con* 
aistenee. Subsequent to the cxatnination by I>r. 
Wollastott, in 17D7, tlicrv have bcco scrcnJ iuiulyi<L« 
of tlieoo ooocri'dons tftkon Fnrni dilTeivnt parl^ of tbu 
body ; one, by Muohaiwl, (rvm the femur, was fuuud 
btfloDOSt of: — 

UtaMofiodB . .84-10 

BnU of lime 318 

ORttout* oTammoDl* .... T'OB 

CblotiJcafM^nn ..... 1113 

Aiuod matl«r ..... SS'SS 

W>Ur O-M 

S-S7 

100-00 



Another analytitfl, by LehmanD, of a ooncretion 
from the mctaoarpuA of a young man wba had saffered 
friiin p'lut, vtta found to contain a great nuuibor of 
four-f<i(l«d prisms of urate of soda, and whvo dried 
yittlded the following reBults : — 

Ontttfmb CSIS 

^VkuoTUbi* . . . f2S 

I of ■odinm .... 9ttl 

■ oriiiM 4-33 

ritaiw S8'49 

jTiUr, kai^ A«. . , . S-S9 

lOO-OO 



Tliere ore other analyses, as tboeo of Laugicr, 
IWuner, aud L'Ubrutivr, whivti closely agree witli 



« 



CHROSIC GOUT. 



each other and prove tlint tlicHc dopo^ts aro ridi m 
aric acid aud aodo, liut iM>ntaiD other eultstancvs in 
smftll ijiiaiitities, as phosphate of liinu, chl(;nde of 
sikUuid, and organic matter. L'Heretior fouod a largo 
pL-r-centage of phn.«])bcito of lime, but garc no dotatla 
GoDcerDiiig the situation of dm concretion. 

All before ub«erTed, then- can be au doubt but Uiat 
tlio cescntjal component in goat>- depoat« is urnto of 
soda, which, in every one of the ntimentus exiuniuit- 
tiuns I huvD made, vras always found to cxhiliit u 
crj'stsllinc form ; tho large amount uf phospliato of 
lirac, occasionally met with, is probably derived, noi 
only from the tissuo in which the deposit has taken 
place, but likuwiso from »ecoudaiy deposition, the re- 
sult nf iinlinarv iulliimmutioD around the urate of soda, 
acting as a furcign body, and which therefore, as in 
the ca*e "f eretawui.'* tubercles in tlie lungs and clso- 
wherc, iniLit be regaidod, not aa lelatcd t'> the disease 
as gout, but as the result of common iiiflammataon 
only. 

Having given a minut« account of the intimate 
etrueturfi and com{}usition of gouty deposits, wo will 
nost doscribe tho principal altoradona whiah they pro- 
duce in and around tlic joints and elsewhere. 

Partial or complete anchylosis, which is of raro 
occurrence in acute gout, fi-enuently supervenes in its 
clirooic forms; sometimes there is no bulging or 
enlargement of tho joint, or tho appearance of any 
cxtcniul deposit; but it is often itceompunied with a 
moderate amount of sn'oUing, and when lias occurs ia 



pisrotmuK or joixts. 



m 



• Email jointo of th<* liiin<t, an iip]K.-tiiRiicp rrpresootcd 
b Sg. 8. 18 prodttccd. 
In the lituid from whioli llio drawing was imuU.*, not 
lly wn» thiTi' suffii'it'nt dpp<«it ti> cftii*> bulgiiiji, but 
Jo vbit4> ptiitits could he e«eu liorc and tlion*, f^po- 
\y nbout the palmar tmia nf the tingerK, sIinwiDg 



r ^5..> 




tic diMc B]ipro*^ of tb> uTat« of aoda to tlio surfiioo. 
WbifD then.' ift no cnlargiinftit, n wry pix;ulittr mid 
«ti}[ulur funn of dirtortiun uf iHnnr of tlio |il)iilan|;oal 
joiiiti* (iftoo nt-ituw; so ehunwiti'mtii-, indeed, lu Ui 
I aSord, to tlio practised eye, almost compltte c\-idenee 
^■tf th« nktaro uf tlti' diituuM! producing it This farui 

^1 * Vic S. A ilnvl^ lt«m ■ nz mod*l. in lb« Mtbnlisl muBon 
^Hv QiJtM^ ColUc*. of >tw buid of ■ )«t>nit (oRtrisc fom chnmio 
^HfMt af maa; ;t»r>' 4unil<nii Mil («|W«*EnU ■ mndiUdii nM wntn- 
^V^M«t)r sMi vilii. A fri> wbiu ^oU an mm vbct* th* olulk-bk* 



« 



t-HRONlO OOltT. 



will !» iigaiii rcfemvl to wIk-ii Uie varieties of the 
so-cnlli-d lUii-uinatid Gout tin- tiviitnl of. 

Coniponitivcly few f^imty patioiits liccoine tlie sul. 
jocte of visible c1ialk>iitoncs, ut leant to the exteut of 
pnxlucinj; dofMnnitv, but I tio convinood that their 
Ooourrcnctt iti a flight dr^rce is by no ineaciB so rare as 
hiui been hithorto aRsunied. Sir C Scudamore Btut«il 
that in Hvc Itundred cases of gout lie only found tbom 
forty-five timefi, or in lees than ten fer cent. From 
my own experience I consider these numbers far below 
the real proportion, feeling contideiit that their exist- 
ence is frequently overlooked, from their boinf; depo- 
site<l in parts of the body scarcely to be expected. 
Smnll concretions are mentioned by some writers us 
having been seen upon the cartihiges of the ears, but 
no particular notice id tjJceu of the fact. Within the 
lost few years I have spmally investigated thi» point, 
and find that, iastead of sueh (lepo!(it« being occasion- 
ally ])rc«cut on the c«r, tlu^ are more frequently 
found there than in any other situation ; * and that 
when they are vu^ihle u[)oii any "ther part, they aro 
usually, but not inTariably, m-en "U the ears also. 

In thirtj'-sevcn gouty patients who were examined 
some years since to ascertain the presence or abseuce 
of concretions of urati^ of noda upon the surface, or in 
such sttuations as to be undoubtedly recognised, it was 
noted, that tbey were present in seventeen cases, 
absent in twenty ; in the above seventeen, they 
occurred in the cars alone in seven ciLses, in the ears 
* M«(lio«.Cliiiurgi(Bl TnuiMCllaai^ Tolung uiTii., 1S54. 



ILLUSTRATIVE CASES. 



03 



nd arouitd the juints in nine, and in one case only 
eoukl ilwy bo recMgiiiacd id olhcr port* of tbo body, 
witlinut being prtt»cnt in tho can likcwisa 

WiUuD tho lut eight ycus I have eought for the 
eGennwaoo of thoso ipota on tho oan in • lai^ge ntunber 
of out*, uid from micli oxpcrienco lun iiiclinod to 
think tluit in femolm tlicy aru siOdoin semj iu this 
Juculity : tlio probnblo tanse of tlits cxcinption will lo 
dwvit on in a 8ubi)('qu«nt chopt«T. SoiiuliiiiM tho 
ipotn are singto, samctiince numcroua ; they are oft«n 
m«Ucr than a pin's head, but now and thea equal to 
» aplit IK-B, or even larger. They hare tho appearanoe 

I of little jtcails, nod are i^erally situntM ahuut Uio 
bid of the hettx : sonuitinies they are hard uid gritty, 
wt mow fretjuently ynyft. und when pmicturvd give 
Brit to ■ milky fluid. Further examination tlwws 
putt when hardened they become firmly atttw^bed to 
the cartilage of the ear, and enlarged blood-voesola 
■re oflen seen in tbeir neiKhbourbood, and even cx- 
Mmo dislunce from Ihem. 
Plato J, fig. 1, 00 oar is re^nv^onted liaring but 
of thew jxjiiita ; it was tlic only e^'idl-noL' of chalk 
it whid) could bo discovered throughout thu body 
llun patient 
The following in on abstract from tlie bi«toiy of bis 

I8M. — J. E., iiged forty<three, a gardener, with no 

tary pntdiRpoeition to gout ; has lived well, drank 

[troely of porttir, and now and then token epirifc*. Tho 

fliat attack of guut came on when bo wu thirty-one 





M 



CHRONIC OOUT. 



years of age, and was confined to tho bdl <>{ the grent 
too, lasting about a week ; the second attack was like- 
wise limited to the same joint> and uccurred about a 
ytar afterwards ; the fita subsequently returned nioro 
frequently, and the ankles, knees, and hands be^aiiiH 
involved. About ten weeks before ho was under my 
care he felt cliilly and feverish, with painii in tlie head 
and oppression uf the chost ; one of his uTists inflamul, 
and tbo head was relieved ; about a fortnight after his 
recover}' from this attuck, which lasled a month, lie 
had an affection of one anklo and great toe. On my 
seeing him. the toe was still tender, pitting a little ou 
pressure, with sigat of commencing dctquomation of 
Uio cuticle. There were no chalk-stones ohi^^n'ed 
around the joints, and no deformity or stiffiiees of ouy 
of tho articulations which had been preriously impli- 
cated ; hut at the upper part of the helix of the right 
ear a pearly white «put wa» scon about tho aze of a 
small millet soed. 

Plate I, fig. 2, nko ropa'snits the car of a gouty 
man, in whom the di»eiue was much further ad^'ancod, 
and wveml otlier uoncrutiouit were tKCn on difiercat ' 
piirt« of hii) Ixidy. 

Tlie following 13 A veiy condensed history of this 
patient's case— 

1855. — J. I). M., u man alKiot fitly-oight yoara of 
age, not inheriting gout, lins been engaged fur many 
yearn iti a cook-shop, and hiis livt<d well, taking mucll 
meat, and drinking freely of porter uud gin. For tbo 
last twenty-fivo yean ho has suiTered from gout, at 



DEPOSITS Olf THE BAKS. 



«S 



fint in ono or other gicst toe^ and at iatcmls of a 
j'far or twu, bat otter a tiino the attacJcs iooraaacd ia 
bw{wmej. and many joictH ntvo affected. For moro 
than twclvp yoan liv lias had rigidity aud difttMrtion 
of aumo of hiH joints, MpocioUy of t)ic hand^ and 
dtalk-stoDoa liuvu formed, aomu of wtiioh have been 
diM-iiBTKcd by ulceration. U]y>n botli cars znany little 
whtlu paints an aocn, an<l Uic blood-vessels leading to 
tbam ar<' dixtend«d ; )■« liad frvqumtly observed that 
bCirD n tit tUo tuini bectunc painful. During tlic time 
ttn potiont has been under my obsennliun, now many 
ymn, the appearaneo of tho «nrs Iiils gmitly chan^^'d, 
a ctreanutance ariinng from tlio detaohmctit of somo of 
tt« old nodolee, and the formation of new oneji ; wli«n 
neent they am liquid, exhibit a beautiful dystallino 
appearanoo under the miorosoopc, and yield murexide 
vith nitric odd and ammonia. Tho blood of this 
patient has been examined two or three tirooA, and 
fiMod loaded nntb urato of soda ; tbo urine is dightly 
•IbomiuooB during a severe attack, but not in the 
tnterrala: its uoalyuH is given in a tinlMoqaent 
(baptiT. 

I havo woo nvcrnl patients with ears rattdi more 
•xtcnsivtdy aflbetod than tlie above, botli as regards 
the number and siiK) of the depraitsL One gouty 
(pantleman at Vichy, who van ondergoing a e»ur«i< of 
the *iratt?r4. i*xbibil(<l a niw of from ten to twcK-i- bi-ofU, 
tiks larigo pcu-K arranged along the edge of t)ic helix 
ofnoaaar. 
Thn iinfwno' i>f dt-pfimti" in tJif cars deserve* ntten- 



J 



H 



CHBOSIO OODT. 



tion, as it may prorn t>f onniiidomblo servino in thi 
diagnosia of doabtfiil cn-ics; I wnuM oWn'c ttiittwln 
I have £uled to fiud thorn in tlio cam of mt'U wlioit' 
praecnt elsewhere in the body, it has bocn in indivi- 
duals in whom thwie orgaus wore unusually warm. The 
deposits are probably formed dunng an attack of gout, 
but occaaionally they appear shortly afterwards ; in 
ono case, of which I have notca, the eais were can* 
fully examined without result when the piiticnt h-ft 
tlie hospital, hut within ton days, on a rc-cxamination, 
a deposit was foimd ; perhaps some fluid was effused 
durin;; the fit, but being at first transparent could not 
bo easily diatinguiahod. Patients with tliesc auricular 
depoate not uncommonly feel pricking and pain in 
tboir ears at the cummencemeut of an acute gou^ 
attack, as in the case above rtlat«?d. 

In only one instance, and that within the last nino 
months, have I met with a pativut in whom the can 
apjiear to have been first attacked with gout, attd 
exhibited dejiosta of urato of soda liefore any articular 
disease had developed itself. The case is intcrostiug 
in many points, and I will tliercfore give a short, 
abstract of it. 

18tU, July. — J. T, a man aged 58, oamo under my 
CAro in the hiiApital ; ho is mairiofl and has had ttai 
diildrcn ; uivt n n-licvin^ officer for twenty-one years, 
whitrb uppuintniont ho resigned three }'cara since on 
Account of ill-hcallh. lie inherits gout from his father, 
and one of his wsters U likowisu subject to it. Has 
boon ucvu^tomod to take malt liquor^ about a quart 



I 



2 



DIPOfilTS OK THE EARS. 



«7 



eaob day, but states that ho hiu alwa)-s been tcm- 
pente. Lot vory im-gular as to bis nciiU ; when about 
aereo yean gf ago is ivported to have luul rbGuinalio 
ferer. vVbout Iwfuty ytara sinoo ho oxporifuctij his 
fint attack of gout> which ho describes bs oommt.^udng 
in tho right hand, but the next day the ball of the 
ri^ht grvnt too bcduiiv affected, aud soon aftcrwardA 
the led foot ud both kiiCQS; the diseosG traToUed 
frwn feet to knoee, and back again firom kuew to feet ; 
Ibe fit huitvd about eight wueks. Two years aftur- 
■nrda ho bad a Hocond attack, and thou at intcrvalo of 
from ooo to throo yc-ure. In tho pursuit of his occu- 
patioa ho wan E^wnd timoa throwu out uf his gig, and 
tfter each fall gout invariably occumxl. 

E About ten years since, depnsita Gomuioncod forming 
in the bandfl and foet, but tho patient utfirnis that 
«fn DS long Ago as twcnty-Sro year;, tlint is, five 
ymn prior to any distinct attack of ortioular gout, ho 
had nuti<M>d nodules on hix oars. 
When odmittvd into tho hospital ho v&a HuSeriug 
■mtfi<ly from azteanTc deposits, wliicli wcro soon in 
tub hand*, many of tliu lingor joiuU buiiig grcntly 
iK^«*.wl uid nodulutvd ; a large lump was full in tlie 
bana of left elbow. The hips, knece, and anklca 
ipfMUVntly uninjured, but the feet moch deformed, 

I the right great too joint ooosiderably enlarged, and a 
aua of depooited matters the stm of an egg extended 
over tho netataisal bones : there was a dcpoeit like- 
wiav on tho hcvLi. Tho luft foot wm tnuch swolka 
tma unitu dopusitii on cudt dorsal surGioi*. and from 

r t 



CHRONIC OOUT. 



many pointii pus was seen exudbg mixed with 
tlialky maltor ; several white points wore seen on the 
left car, iind one oii the right car. The urine giifc (lu 
snalysis scrarccly a trace of uric noid, ^. gr. 1010, 
irith u smull ttmnunt of albumen. 

Gouty oonorotions an* cumraonly situated upon tlie 
luuidj iiud foet, but tho upper extremities are more 
nsuitlly aiffcled than tlie lower. A short time sinee, 
in 1858, a gentleman was under my care whose case 
well illustrates the eaily development of these de[Kisit& 
He was abiiut 63 years of age, looked healthy, and in 
gvod plight ; bad suffered from ^uty attacks during 
the lost twen^-fivo yeais ; at first they were confined 
to the great toes, tbiTy tJicu gradually alfoutod tho 
foot, ankles, and kut^ixs, but lattiL^rly tbc bands went 
also involved. He bud an attack in tlie.«pnug ufthot 
your, which was more Ifiigthenwl tlinn asual, nnd hs 
afkrwards observed tbut womo of the articulations of 
tlio fioj^rs romuined slightly orii)pled ; in this oon- 
dition be fir«t applied to mo. The las-t pholonj^^al 
}oint« of two or three fingew were BtifTcnLiI, partially 
anohylo«cd, and a little swollen, but ou the donol 
surface of the second jiludangcal joint« uf tlircc fingcn 
small rounded protuberanees were ob«f rrod, tho skin 
orer them beinp: red ; these hulgings appeared soft, as 
if euntuining a tbiek fluid, but not the slightest indi- 
cation of white matter ciiuld be seen through the skin; 
thoy might have been cither goaty conerutions in their 
early rtage of fonnntion, or some other fonn of 
Bwolliug ; from a (umplo inspection I could form no 



siTUATios or Gorrv co cbetioss. 



w 



^B optnioo as to Uioir true nature ; but tlio history- con- 

^P Tiaaid me tLat tiwy antse from u Joposit of urate of 

r iada. Upon puucturing one of the litUc swcUtags, 

fitU light was tbrowti upon tho hujo, as u thick white 

fluid immcdiotr'lj' cxudod, a drop of wliidi yiaced 

I oadcr the microscope, n-ith tbo use of p<jliiri^cd light, 

I f!STe tho appc»rance represented in %. 7 (pBg« 67), 

I which was drawn fit>m the ididc in which some was 

pKMrred ; the crj-staU were proved by anal}-sis to 

eonnst of urate of soda. 

^B Thuec MwvUin^, as they increiuo in az/O luid btx.'oino 

^■FBOre solid, approneh t)io xurfuuo ; the .-ikiu becomes 

^PUhntner, and tlie jioctiliar white iippearunoe is then 

•MD, whicli at uacc reveals their character as obscrt'cd 

ia the givst toe (Plate 1, flg. 3), and in the ears Mote 

nfcned to. The bistoTy of the mun from who»o too 

j^ Uka drawing was made is shortlj* this : — 

^P 1654. — T. C, aged 67. A house puiittcr for forty- 

Ikrev yoaw. Has lived w«ll and dmnk freoly. Uis 

poaral health had b^eii good till u-itbiu the last 

l*«]va yctm, when be fell frum a Ktiffuld and shortly 

afti-rwards bod lead colio, Gont then commenced in 

L the ^-nt tite, and the attacks have of late years 

much inoreaswi, both in scvcrit\- and frequency ; 

w thn von, and around nuincnxis joints of the btHly 

bendcs the delineated too, many white uratu dvi>usits 

an risible, somi- of canstdembk> size. 

Juinta amund wbiuli chalk-'<tonc8 have formed. 
tnoooke dislort£-d in proportion to their number and 
otant, until at la«t the most fearful orippliiig occa- 



TO 



CHRONIC OOOT. 



trionally ensues ; raofa, for oxaniplo, as is rcpn^ontcd 
in the band in Pluto 3. 

T}ii8 tuifortimate patient, J. E,, the time thiit tlio 
draicing was Toado of his arm and hand, was aixty- 
sevon yeara of age ; HitiL>o bis boyhood he hail lived 
as scn,'ant in different families. At tiie age of 
thtrty>t(ix be had his first attack nf gout in Uie great 
toe, and for many years tbo fits returned at short 
intorvals : when about the ago of fifty-tirec, tumours 
formed on the fiogora and elbows, and subsequently 
about tbo joints of the foet, theao swellings gradually 
increaiied in size, and after a while a fluid of tlie 
consisteucc and ooIdut of crcani waet di.<chaigcd from < 
AOmo of them. The tumours on tbo liands and 
elbows wero considerably lar^T thau tlioso on the 
fuet and knres; the niuvem<.-nt8 of the elbow -joint 
were not much intcrfcrud with, but think' of tbo haudj 
greatly impeded. The patieut'it niulber, {"lundmother, 
and brother, wcru affected with gout, but in u ias$ 
degree. I havo in my possession a chalk-stone taken 
iniin this miin, which ic a recent state weighed moro 
than two ounces avuiixliipois. 

These exaggerated funns ure not vwy commonly 
iDct witli, although wiUiiu the Inst few years I havo 
BCCD many ciisl's in which the hands were almost u 
much disfigured. 

^e various bunun muoosio are very liable to become 
influtood daring an nttaek of gout, and after the 
Ma(« inflanunatoty action ba« passed off, may remain 
diBtended; this diatomion arisus from a Buid ba\-iiig 




81T17ATION 0¥ OOl'TV CO.Vf ItETIO.VS. 



71 



I 

I 



itad in tlunr caiitiefi, a fluid whiclt oIVmi 
gnat rue to m deposition of solid matter, and heiicH] 
rami to tho fomuttion of pLTmancnt ohalk- stones. 
The bona over tho olovmuon procoss of the eIt>ow- 
jotat ia iwculuu*))' pniic to be thus di.-ftvud<.'d, and iu 
Bway caaeB we &id its wnIU thickened and n little 
kard nodule is felt in the interior; sometiiaes, from 
tTpoatei] sttucJcs, it becomes eDonnoUBly distended, ns 
it well showii in Plate 2. ^Vliea no solid matter c&u 
bo i^t through tho wulU of these enlargod burss, they 
will occasioDmllf , if puncttinHl with a fine instnitnont, 
give riso Ui * fluid i-xudatioit, having the cryet«Uiuo 
choracten already dctjoribed. Tliu fuUowiug ca«e, 
vhicli rocentJy occunvd iu my pmclieo, well iUu»- 
tnliH thifl fact : — 

1858. — W. ¥., a man ag«d nxQ'-ooe, has had 
(oat fur fourtMn years. Thu first, »s aim aoTeral 
of the subsequent attacka, were contined to the ball 
of the great toe of right toct, tlio li'H groat toe 
tlwD beoBme affected, and aftonrards the olbo«-H. No 
dvpootH of chalky mattor were anywhcrv vixiblo, but 
ihc) hurra orcr left olecranon process was enlarged and 
poounent ; tho wallt wore thickened, and felt «ome- 
wb»t clastic, and tho iikin red ; llie patient bad 
nflered very recently from an acute attack in one 
«f the KTBOt toM. Fot-ling somewhat doubtful as to 
the obaractor of tho fluid within the sac. it was can- 
fully poDrtared. and nearly half a drachm of n wliito 
taalter vxudod. which exhibited tho cluiractcristio 
oyitaltine npp^tamnne we have so often referred to, 




>a 



CHRONIC OODT. 



due to the prcftonce of iimumuniblc pHsaui of urate 
of scKla. 

The bursa about tfio knoe-joint is bIho liable to dis. 
tension, and permrtni.-nt ciilnrgtincnt niity result hum 
the (Icpoaition of gouty matter. 1 have now under 
my care (October, ISoS) n jiaticnt who exhibits this 
deformity, and likewise a roiniirkublo di-^tortion of one 
finger from a liko cau»e, which is re[ire^-ntod in fig. 9 
(pogc 73). 

Tlio history of the case and liis present condition ia 
08 follows : — 

J. B., a man aged forty-three, by trade a ptamber, 
having no known horoditary prodispoeitioii to gOQt; 
t4.-nipumtc in his habitt, but accustomed to take aboat 
two pints of porter a day ; has suffered severely from 
gout for twelve or fourteen years, ohieSy in spring and 
autumn ; the first attack, which affected the great toe, 
oocurred as far back ns twenty years ago ; after this he 
had a respite of some- dunitioQ. About ten years since, 
the disease made it« appounmce in u more guneral form, 
many other joints, bexidoi tliu great toe, being impli- 
cated ; from this time the disorder bccamu frequent in 
its visitations, and serious in it« charuuterit*tio«. 

About five years ago, ho notiood eolargoment of the 
fin*t phulaiigenl joint of the fourth finger of the 1^ 
band, apparently induced by running a pieeo of glan 
into it, but subsequently deposits appeartKl in many 
other eituatiuns. A\Tjen the patient came under my 
core the following notes of his condition were taken : 
— a divtinot blue line is eeen od the free mai^gin 



BtTl'ATION OF OOfn" <:ONCKETIO!W. 



79 



of the gums, whkli, us woU as the Ups and suifaco, 
■re somewhat anffimiatMl ; he has noror had lead 



< 







I 



PI(. fc- 

oolic Upon tbo helix of the right oar two small 
white «pot« arc ohaun'od und dopositti can bo distinctly 
fitlt in the buna orer the left elbow ; both Imiids uru 
much dcfonoed, many of tlie phnlniigi.-ul joinU aro 
•ndljrlosed, aod hero and ther« the dcpoAiti* iipproacli 
« Donr the rai&ee as to resemble white patches. The 
Bnt phalan^ipal joint of the fonrih finger of (he right 
band ia tnoet deformed, and swollen atmoet to the sixe 
of a nnall hen's egg, the long diameter of the tamour 

* IV », A dnviof it Um band ot • ptlknl In CDlrfniir 1>M»a» 
BMfiM^ I* wUeb 1^ Gnt ph^ugekl JotDt i( llw banti fingar of 
tl^ hMd I* abcva Mtrtmd} Milart^ from Iho dtpoiUoB «f wBt* «r 
■JaaraudiL 



74 



CHKONUr (lOUT. 



boing tmnttvcrsp, and overlapping tho fitigcrs on 
eadi tudc, us shovra lu tliti I'Dgmviug, fig. 9. Tho 
swelling is red, tense luiil Hhining, the blood-reneli 
dibU-ndod, giving u KoOBiitiou to tho touch of btiing 
wmpoeod partly of solid, purtly of tivtrii- fluid matter; 
it has been incrousing for muny years, aud doubtlen 
cousin of iirato of soda of different degrees of oou- 
i«iRteiicy. Both ankles and tho right foot are enlarged, 
but not axlomutous ; on Movoral of tho toes little white 
points arc Hc-eu, trom which chalky matter has 
formerly cxaded ; tho buru over the prttella of tbo 
left knee if much enlarged and bulging, with several 
white spota when' tlie dcixisit ha-i approached the 
vurfnco, and fmin which mme h)i» occju<ionally been 
di^chiirgod. Tlio urine i» pale in colour and roUivr 
ubundaut, it« avenge specific gravity 1010, «ud 
during an attnck of acute gout, xlightly albuminous, 
exhibiting both granular and waxy tubular caitt». 

Kot uncuminonly, OHpccially among workmen who 
are accustomed to use their hands in grasping toots, 
white deposits are seen on the palmar surface of 
the ends of some of the fingers, on accoont of the 
nutter which was originally deep-seated becoming 
more superficial from constant friction, and I have 
recently observed the same produced in the right 
hands in gentlemen who had beeu in the habit of 
writing much. 

Sometimes smnll nodules of urate of soda are found 
upon the eyelids, and now and then in the integumonts 
of tho fni^ ; Dr. H. Barker has seen one on the ode 



srTDATION OF OOITTY CONCRBnOSR. 



76 



of the nose, tlie axe nf n honivbcan ; and in on« 
iiistanoc I obccnrcd « true gou^ deposit as large as a 
split-pcOt apparoatly attached to tho fibrous Btruoturo 
of Ui« corpus carornosum of tlio poois. With regard 
to thti white-looking deposits which often ocour bIiouI 
the eyelids md tho intvgunicDtt of the fiioe, I may 
remark that some c«re ts nocnmiy before deciding 
upoQ their nature, o» they are seen in suhjccto who 
have never had gout, and abo in gouty patients, and 
still may not be connected witli the disciiKt, nierely 
connsting of epidennic scales mixed with fatt}' matter 
and cholesterine. I hare recently examined tvro 
vbite deposits from the same individual, a martyr to 
gout ; one takua from the helix of the ear, the 
other fr<)m the under eyelid ; that trom the car wo^ 
crystalliiio und coiisii^tcd of urate of soda ; that from 
tlic eyelid was niiiply ecbnceous. 

Since tho publication of Uie first edition of the 
preeent work, Dr. Routh kindly sent for my initpoc- 
tion a young woman hanDg a nodule upon the left 
cor, about the axo of a small bean \ it had all tho 
outward appearances of a urate depi^it, was somewhat 
hard, very white and opoquo, but when punctured ttio 
matter vas found to consist of ei>idcrmie 
Ttad &t, and to yield do truce of urio acid. Tho 
pstknt, about twenty years of age, was not descended 
from gouty parents, and liod oovcr suffered from any 
articular dim.'ase. 

After patients have suffered from gouty concrotioofl 
for a long time, it is not uncommon to lind that tho 




7a CHBOXIC OODT. 

skin over thoiD Locomia tliin, and £ragmonte of tbt 
vholk-liko matter am thrown off uccusioiitDg little 
anuoyuacc ; tliis oflca occurii iu the fiugers, toc», uiid 
hcul, eumctimes ov«r tho head of thu tilia ; ia th« 
ears it is of rcry {reqnent occurrence. Bat on the 
other haud theso dojx)8its tuny act aa foreign sab- 
stances, and set up coDsideiable inflamiimton' actioo, 
oocompanied with suppuration, and by this means 
ulceration io induced, which often proves dil&cult to 
heal ; when such is the cose, the discharged matter 
oonsUtrt of small Tne«»cs of aratc of soda mixed with 
pus globules (riut«6, fig. 3, and fig. 6, i). My own 
exiH^-riencc would loud mc to bolievc that the coadi- 
tiuu uf the piiticut's gcuvriil Ik-hUIi bw oonndortUo 
iiiflucoco iu t-uch ca«c8 in o»ui<ing ia£amn»taon and 
suppuration around tho deposits, tlio lower tho vitality 
the greater teudoncy to tuko on iiiflummator^- action. 

A very interesting end valuable paper on gou^ 
oonorctiona is contained in the 6rst volume of the 
Medico-Cliirurgical Transactions, lrt09, by Mr. James 
Moore, Surgeon to the Second Regiment of Life 
Guards. In this communication the mode of formo- 
tioQ and progre-is of these tumours is so graphically 
described that I have been induced to transcribo a 
portion. AfWr b few preliminary remarks as to tlie 
natore of cliolk-stoncs, ho goes on tn state : — " This 
effunon (mooning tlic milky fluid containing tho nrato 
of aoda) occurs not only during fits of gout, but Uko- 
vise in tho intervals ; and as tlie cxtn-tuitic«, particu- 
larly tho hands and feet, ar« the pn'ucipul scut of gout. 



GOUTY ABSCESSES. 



it t« dam tli« gtaitokt aoomnulatuw of vhalk tukc8 
place. Tliou(;li this proooM is usoaUy pi'cccdi<d uiid 
aocomp«ii«d by infUunDUition, the cbolk is nov«r 
induacd in a cyst, lik« piui io aa abwcss. It lice 
usually in tlie celldar meiDbrano, in tbo 'ImrMO 
mucosa}, or in the caridrs of the joints. I hiivo cvi-ti 
seen it thrown out between the cutiit uud the cuticle. 
But, as tlie gouty inflnntmation is of the erytbcmft- 
Unis kind, there ii no cxtrai'SBation of coaf^lablo 
tyinpb, and no new-formed covering nurrounding Uio 
ohalk. This point is of the fintt importance, and 
explaina many of the pcculiaiitien of gout, which is 
generally oonndorcd as a phlegmon. But the ah- 
Donoe of coogulable l^mph in the inflamed parts I 
eODiider ns full evidenci^ of tlic inflammation being 
eiythi'Riatniii'. 

" The chalky liquid when 6nit secreted gircs to the 
finger tlic feeling of flactuation, and cannot be distin- 
gnisbcd from the ordinary serona efliLiton of gout. 
But unfortunately tho ab«»rhonts cannot suck up tlic 
clialky particles. The consistence of the liquid, 
therefore, becomes tluckfir and thicker, till at lasit 
nothing remains but n Imrd maa. When even a 
oonaderablfl effusioQ of this kind accurs, the qoantity 
of chalk which ultimately remains is comparatively 
small, as by far tho greater quanti^ is merely serum. 
It therefore usually requires repeated effusions to form 
any great mass of cbidk, and the conHStcney depends 
upon its age, and the activity of the abeorbeuts. The 
quantity at last accumulated hy repeated paroxysmfi 



CHKOSIC OOUT. 



is in some inittRnecs immcnso, which nogmonts Tory 
seriously Llto mtfTcnn^ of tho gnuty. Tfao dutrooe, 
however, is not uwiii^ to nny irritftting quality in the 
chalk, hut to ite. obstructing the nrntion uf tlio tcadons 
and juiiits, oroiMciuing often complete nndiylosis, and 
pressing und diKtoixling the suiruunding purts by ito 
bulk. It nets, thtTuforo, by mechimieally vmbamsriog 
the machine of the body, ntid not upon thu living 
principle! ; fur it will uft«n remain for yenre in parts 
higldy BE!n»iblu without exciting tho tdiglitcst pain or 
iDllntnmntiou. Altliough the^ coucn-tioos are of so 
mild II uuturc, they ofk-n nro tliv caoso of oxtcnatTO 
mischief, bursting oxtonially, liCCFisiuniiig ulcers very 
difficult to hcrtl. ^V'hc^ a violent tit of the gout 
ftttack:4 n chalky tumour, the appearance is fVoqucDtly 
veiy alonning, the new paroxysm being acoompanied 
with a freah serous and chalky effusion, which added 
to the old deposit of clialk, occasions a prodigious 
swelling; the cutis when distended to the utmost 
opens, TCt sometimes the cuticle remains entire. Tho 
chalky or serous liquid may then be seen through 
tho eemi-tnuiKpnreat epidermis. The surrounding 
iut«gumonto appear of a deop rod, or of a puiple 
hoe, thrcntC4iing mortificutiun ; while the pain is 
excruciating. 

"At length the cuticle give* way, a discharge of 
serum and chalk takes place, and a remission of all 
the K)inpU>ms usually t'i>ll<ivi*s- During the whole of 
this ahinning process suppuration never occurs ; but 
Boon alter the opening has taken place suppuratioa 




COUTV ABSCESSES. 



71 



^ 



^ 

W 



flfuumencra, and poB and ohalk itru then dificbargcd 

bvBt tho nicer. There arc snreral unoxpcatcd occur- 

rmoot in the progress of such ulfX'nitioiis. WHien an 

opening ifi f-imuHl, the whole ui tho chalk never 

eaesprs and its comiileto evacuation in oflon u vcr^' 

tedious (iroocos; this is owing to its being diffused 

tbruDgh the cellular membrane, as in the cxAh of a 

mpon g B. One evil must sometimes give way after 

another, and amull iK>rtians of chalk are successively 

thx^iwn out, su that montlis nod even years pass away 

boliini tho whole it discharged. It also frequently 

lifl|ipens that tliv onfico contracts aud (iIumm) over, 

lesriog portiotu of dtidk underneath. Thi-i kind of 

(Matrix aimtftinua itondfl it» ground, but more com- 

mooly breaks out again and agaiD to discharge chalk. 

ETeo oiMiiiiigH into joints, which arc so <litnK<.'r<>us 

wfai^n occuaioDcd by other extraneous biHlies, are often 

BttcodcNl witli no urious symptoms when tho joint la 

SUed with dialk. On utitrh an aoddent hapjK'ning. a 

Mli^'on unaci|uainti,>d with titeee peculiarities might 

fan tomptMl to propose large openings or even wnpo- 

tatiim. as tho only resource for hindering estcnsin) 

inftaainiation and carious bones. But if he treats tlio 

iti»inin mildly, ho will find that no sacb severe plaiu 

are nxiuiMto, fur the parts will probably &11 into a 

rer>' traoqtul or indolent state; a sore will continuo 

Cur a certain period, discharging pus and occasionally 

a bit of chalk, till at last tho orifice will clow up 

lodcpvndeot uf tlio openings formed by a fit of tlu) 

gani, the skin, atretdiwl ovur a maaa of chalk, is 



(wmetimefl tliinncd, atsorbed, and piereod hy mere 
prfssiire. At other timcft tliis is iffectcd 1>J* common 
iitHammation and suppuration. AVbca openings talie 
place in tlieso milder ways, ii less quantity- of chalk is 
osually evacuated : but this depends entirely upon tko 
degree of ioilammatioQ. ^Tien the suppuration ia 
grvnt, it naturully detaches and w««lii« out u greater 
quimtity of chalk. 

" Tile lajit piHiiiliarit}' is tho rarest, nRmoly, that a 
dry hard piece of ch^lc shall pierce tlie skin, aad 
renuiiu like an oxcrosccooe, without oxcitiug oitlter 
inflummntion or suppunttion." 

The point upon which I sliould feci dispriscd to 
diSer most from this writer, is with regard to the non- 
occurrence of suppuration prior to the opening of the 
ekin ; as I have seen many ahscesses fonuod aroond 
gout}' nodules, which have at once given exits to a 
largo amount of pus, as well as urate of soda, on being 
punctured; this has occurred in patients in a woak 
state of health. 

It not uncommonly happens, that when patients av* 
sufl'erinj; fniiu gouty absoenoe. which are keeping up 
a constant discharge of matter, they enjoy a compa- 
rative immunity from other sj-mptomn, and I have 
kaomi several inRtanco-'i in which tlie healing of these 
ahsceasca was followed by n sluirp attack of gout is 
some other part of the body, lowing tliat the ulcers 
had acted as a kind of safety-valve. 

Some pjitieiit'' appear remarkably prone to the 
formation of jjouty concretions, while others, even after 




ILLHSTRATtVE CASES. 



SI 



a coomdoniblo onmlwr of fits, rrmoin entirety fVoe ; 
tin* mnarlc, it must bu remcmbonxl, only applies b) 
deporits of iiroto of ttoda nmund the articulatioiu, for 
all, OB I shall presently prore, Imvo altcratii>nH uriUiin 
llu) joints. Although it \k much more* canunon to 
•laerre the deformities produced by tliiti dimrder among 
mm, Cbmidcs are by no means «xnnpt, niid I have had 
Oder my can> several w-onim exhiliitin^ thi» form of 
(be a&ction in a ver>' marked dc^ce ; in ono Indy 
both the upper and lower extremities were stiffened 
and distorted by tho bulging of nearly hU the smaller 
jaiota, and the imtient, who wiut a1i»nt forty-thn-o 
of (^p', hiui l>oo<>Rie cotupletely crippled witliia 
yean of the fintt nttaolc uf tho disease. In 
flSBO th« defonott)' was muob tews marked, 
thn bands vere nodulated and rendered 
itawat oscIms. Tho late Mr. Samuel Cooper related 
a nmibir inntunoe he hud seen id » Indy not n»>rc thuD 
thirty yean of age, at the Fk'ot priwn, who wnit in 
•ad A atato from dopodts iirouiid tlic jotitt'*, that hcr 
Emh* WPro of little or no use to iter, oiiil when her 
kMaa were bent and extenth^d, a mUling noLvt was 
fRKhwed tilu- thnt which would nnV from sliakin;; a 
htg td mazhlet. 

Within thv Urt few nontlifl I have hod under my 
tkmrgo to thu hoapital a female in which the deformity 
■nainif from gout is iJiown in a rcrj- oxtreinn dcgrcv, 
aad an her cnae is iiurtmetivc, and in niuny pinnta 
pMxtUar. I will gini a iJunt kbstnict from my eaae- 
book:— 





CHHOKIC CIOUT. 



M. A. F., aged fortj'-ninc ycarf, married, has hud 
several mUcarriageH, but no family ; knows of m> licir^ 
ditarj' prcdiBposition bo gout, bat vrm always delicato 
from tlio age of nino yoara until tihe was twenty ; she 
Uvod with ht:r aunt, in a publiohouac, as hanuaid. Slie 
wiw advised to take a little port wino on account of hi-r 
weakness, but sho soon incrpaapd the nniouiit till slin 
drank a cnnsidcrablt-' quantity each day. At tlic n^ 
iif twenty-nine years she experienced her first fit of 
^ut, coranwrncing in the right groat toe, but within a 
few dayB implifatiiig the left thumb ; the attack, how- 
ever, was not severe, and she was soon able to reKumo 
her occupation. The attacks atunied at intcrrolfl, 
witli mmh-rHto seventy, until about i-iglit yi'ani once, 
when she was so extremely ill as to seek admii«i«n 
into the hospital, and came under my care. At Has 
timn she not only suffered from joint affcctiou but also 
aevero epistaxis; concrctiotiH of unito of Roda hod 
already formed around many of tlie joints of tliu fingcn 
and toes, and the urine was very pale and of low 
specific pTivity. After remaining in the hospital about 
two mmitlis she left much relieved, and was lust sight 
of until her rc-udmission in June, 1861 ; during this 
interval, a period of eight years, she had suffered from 
repented fits of g()ut, and gradually increasing de- 
formity from the rapid dei»osition of chalk-stonn. 
Tlie state of her joints was uow frightful, the hands 
completely cri]»plcd, the fourth finger only being move- 
able, or iu the least approaching tbc natund shupe. 
A tepresentation of the left hand is seen in fig. 10. 



MXirsTltATlV'E C-A8KS. 



S> 



Ttu) left elbow vftts HwoDtii from a deposit over the 
l«>locniiiun process, lh(> knoc-s imUiged aiid <Itjformed, 




Pit 10* 

and both feet greatly dtstoried ; on the mutatantal 
bono uf the right grrat toe wbs a large niaas of chalky 
dopant, alwut 2} inches in lengtli, and 1 J inches in 
breadth ; the gr^at too itas also much swollen from 
tfac MHie cause. These appearances are seen in the 
iitrDrxcd woodcut, %, 11. 

Souwoly a trace of nrie add could be di«eoTen>d in 
thi« ptttientV urine on anal^'si^, and the daily excre- 
tkm of an-a was rcrj- <le6civnL Bc«id(») the deformity 
bnm the exccwive dopomts of urate of soda, the chief 
featarm cxhibiu-d by thiH patiatit were extreme pallor 
of oomplt^xiou from ieipniwd nutritttui and impure 
bloud; the ftvquaot oceurrencc of cptst«3cis, cbnMiic 



nt, 10. A ilmvlBl or Ik* UA W«l of • vOMB la Onlrmiv 

q 3 




riTUOSlC (iOlT. 



vomiting, and virtigo from the renal lieficdencr ; «ho 
also nociisiuiially had nttacks nf dysutia, and eomv 
. yenTS MIR1.' hiid passed a small uriimr^' calculus^ 




An excessive fonuntioii of dinlk-stones is, I beliere, 
inrariably <!Oi]iiuct«d with dcfloient eliminating power 
of the kidneys, as will l>o rdiown in the chapter de- 
%'oted to tlie eoimiitcrntidii of the iiriue in gout, and 
in many coses this can lie more or less distinctly traced 
to the influence of depn^iiig causes, as an impo- 
veridied diet, arising from sudden reduction of cirvum- 
Btonoes, a severe shock to the nervous ><j-stem, debility 
from the supervention of other diseases, and so forth. 

Several eawA, apparently arising from fome of the 
above- mentioned cauAen, have been under my core 

* Vif. 11. A drmwiDjef lie ritht tool et thr nine wiisi«» fren 
whom tb< dt'lInotiiciD of the buml (fig. 10) nu obuiucil. 



ILLCSnUTITE CAgES. 



81 



(luring the last few yean ; the folluurmg is lu cxumplo 
Bclectcd from them : — 

1851. — W. U., A man aged fifty-oiii% with no 
hcretlitaiy prcdispositioi] to gout, whi-o itLout sixteen 
j'ears of n^ wait to wirviee ■* etowitrd's-room boy, 
nftcrwardfl became ixistilinn, wid was Nceustomcd to 
drink as stablemon usually do ; ho was often oat on 
tho box all ntgbt> axposcd to vwt uul cold. Id 1S29 
he vent to the Mcdit^MTuncan, and travelled through 
Franco, Italy, and Svitzcrlend, in the capacity of 
gCQtloman's ooaohnian, and partot^ freely of the 
now vbes of tlie countrios, and aim of brandy. He 
returned to England in 1880, qutto well, hut had 
soflered &om some brain aifection when abroad from 
oxpoeure to the ea.n. Shortly after tliis he expe- 
rienced fits in the August of each yvor, which were 
oonsiden.'d to bo cpfloptiCr and these obligvd him 
to dtAoontinuo service, and to live very aiiaringly. 
The fite continued until 1845, when tliey terminated 
upon the occunmce of gout in tlio ball of tho right 
gnoit toe. The first paroxyisn lasted about ten days, 
and lie had no return for a year, when both ftjcl 
were a&cted ; the attacks after thiti rapidly increojied 
in £requenoy and [severity, and the hands, elbows, and 
knees beeanie implicated. As early as after the first 
eeusure in the upper extremities, he noticed some 
white spots in tho tip of tlie right tittle finger, and 
soon afterwards numerous deposits took plav« around 
obaoet alt the smaller joints of the hands, and many 
of the &et> and nodules were also seco on tlie ears. 



8iJ 



ClIUONIC OOUT. 



At length ho bocanio complexly erippbd nod de- 
formwl, 8i)nio of the di'i>i)sit'i gn>wiug Ut a large size, 
Riid cuiu^iiig ulceration uf the Akin, niid ubst-ciuM in 
difffa'nt jiarts. The urine was very Jiule, with a 
eltght triiov of nihuiueii, luid ecanx'ly ouy urio add 
could Ix' svpiirntixl fnim it. 

Ou the other hand it frequently happens that no 
deprosfiiug cuu»c can le shown to huve acted iu tho 
production of tliosc depo«dti>, and now and then thry 
occur in patieDtB whono oonRtitutiotiis nrc in other 
ri-»]>oot8 exceedingly go<>d, and in whom the force oud 
tho duration of the disease must alone he looked for ns 
cause. A gentleman »cca.<iionally consults mo, now 
about cighty-niuc years of age, having both bands utd 
feet extensively eiJiirged fi-oni depomts, many of wbicih 
have formed ahscesscs constantly dutoharging urate of 
soda. 

Another case in wliich the gouty eulnrgenionls wcro 
excessive, tho hands of the patient being tilmo»t us 
much deformed aa that represented in Plate 2, was 
under my oiire about five years since. 

1857. — llif. gentleman was sixty-one years of ngd 
and had no hereditary' predispoflidon to gout. In 
early life he lived frctOy, partaking chiefly of malt 
hquors and spirits. Has luul n very hirge family, all of 
whom are healthy. The first fit of gout came on about 
thirty years since, in tho hall of tho left great toe; 
there wa-s only an inton'iil of half a year between tho 
fir<t und seoKud visitutiun, but sevcnd years elapsed 
before the kuecs wcic uttiwkcd, and still a Imigor 



ILLl'STKATIVK CX8ES. 



CT 



Vim 



pcrioti before any of the joints of the uppei- <>x- 
tmnitics became implicated. Fur tlic Iiist ten ycai^ 
has noticed chalk £tone<s and is now extremely 
'deibrmed and cripplt-d by them ; all the joints of the 
liaads are completely studded, as likemnc are Loth 
«Ibow8. The feet arc much dL-«torted ; tiirgc masses 
are Bcen on the inner aide of the left tarauR, from which 
{ragments of white matter have been discharged ; and 
there is much thickening iimuiid each heel. Both 
e«ts ttro studdi'd, aiid some of the nodules arc of 
eaoodcrablc eixe ; depoeitK are also seen near tho 
jioacr oanthtu of codt eye. 

Qo comi^aina of but few uucumfurtublc 8ymptoni$, 
otluT than acidity and he^uibuni, but norlli winds or 
the Imift indul|>ono(' in wine or ale, arc vt-ry apt ta 
nidaco frcidi iuibimmalioa about somi.< of tho crippled 
jotutii. 

Rv nHBOmbon that bis uriao formerly throw ilown 

xvi Mdhneni, but of Iitto years (the la.'it vix or seven) 
h hM It'comi) much [uder and c<}nipleti.'ly free from 
deprnt; at invHont it i» of low stpceifio gmrity, c<>n> 
tatntng a distinct tnuw of albumen, but yiolding 
wmmAy aaj uric acid. 

Cbalk-stonM may be occasionally traced to itijunes 
whkii, however, net Himply in localising them ; I haru 
^9ra Hunn on the bock of the hand, the result of blows, 
o&d it ii pnibablo that the collections of urato of sods 

kin the bursa) of tlic elbow iio oftcu oboerred uriw 
from Lh<i pntwuro to which they are sobjcoted. 
Sydunbsm'a aooount of the progrvM of ohrouio gout. 



w 



i 



»s 



cHttoNic Gonr. 



Biid of tJie HufTerings and dofonnities produced by it* 
ifi equally correct and giapliic with liis delineation of 
Uio aculo tit, and I cannot, in concluding tliis chapter, 
do otherwise than bring it before my readers in his 
own emphatic words : — 

" Wlieu eitht-r unduo treatment or the prolon^^ 
delay of the diiwoso has converted the whole Ixxly 
into a futius for the pcccuul mutter, and when oaturo 
is iucomi>ct«iit to its elimination, its course is dif- 
ferent. 

" Tlie true scat of the di^-»sc is the foot, so muoli 
BO, that whou it npiH^^um olHowhorc it« character is 
changed, or else the constitution i^ weak. Then, 
however, it attacks thu hands, wri^ttd, elbows, knt'es, 
and other parts, the paiiis bein^ as tho [Miius of the 
feot. Sometimes it distort;! the fingens thOD they look 
like a bunch of parsniptt, and become stiffened and 
immoveable. This is from tliDdi.-puMit of chulk-stono 
concretions about the lignracats of the knucklt^. Tho 
effi)Ct of thceo is to destroy the skio and cuticle 
llien you have <ilia1k-3<t<>nci< like orubs' eyes exposed 
to view, and you may turn tli^m out with a needle. 
Somotimi's the morbific matter fixes on the elbows, 
and raises a whitish tumour, olmoHt ns large ns on 
egg; which gntduully grows red and inflamed. Some* 
tinits the thigh fcwls &a if a weight were attached to 
it, without, however, any notable pain. It descends, 
however, to the \anx, und then tho pain is intense. 
It checks iJl motion, tiiiils the patient down to his 
bed, and will hardly allow hiin tu change hi» posture 




SVDENHAirS DItSCRlPTEON. » 

■ hair'ft- breadth. Wbenovrr, on account of Uio rott- 
Icnnces m xxeaal in the disease, or from luiv urgent 
nMemty, the patient lias to bo moved, the greatfjrt 
Mntioa is nea-ssary. The least contrary movcmc-nt 
noics pain, which is tolerable only in proportion as it 
ii Bomcntajy. This movement is one of the gri>at 
tnabW in i^t ; once with perfect qaict, tho agony 
i* jtwt tolerable. 

** Up to a certain time, the gout comos od towards 
fbo ond of winter, lostA for two or thr«o months, nnd 
rvtim regularly. AflerwardH, however, it lasts 
throughout the whole year, exct'pt only the hottest 
noathii of tlio Rummer. Furthermore tlie longer the 
attack, in gmoml, tho lon^r is ouch individual fit. 
Zattoad of a day or two, tliiy taet n fortnight. In* 
Head of the foct, tfaoy attack any joint indifiVTontly. 
l«atly, on the first or »coond day afU-r, tlie patient, 
bondm the pain, has Una of sppolito and general 
diwomfoft" 





BLOOD IN GOUT. 



CHAPTER IV. 



■uoD IK Oon :-Ai,Tii»D toiTDiTia]! ur »■ blood n oocr omM 

MttVXMIJ BT TflS OLCn WKITKIIS, KOT PKOVKD DrTIt, TBET 
MaBRI.T— OOHImBtTtOX Ul> TUN MlWt) Ilf IIK1I.TII— ITS AtaX- 

atTioii IS QDCT — atatiui.as — rinux — xi.bckkb — miODVtK ov 

tllUTi Of K>ti* IK mit III.OOD— MUDN nt MPAkjITIND DUO ACID 
AXD rtATR or 90111 VauH IT— C1.1IIIC1I. KETIldll fOK fCISK- 

miuio im i-Kuvnoa or iwo ioin iv Tim ninoii— ^RTina 

IHD rntajlUTIOHS— MLICAOT or I8» T1»T— KKini DHOOBron- 

rtoN 111' vuo loiD u THi BLuoii— rKoBABtc oniNon wnint 
KKgni — TAMK coKTitiniia « luoKT suHiixBT or cmn or mdt 
IB wnroB itwo aoio was pnoriiti to »itm tK Ta« iLoon — 
MsoaviHT or drio xno ii rLDiM xiTtrioiibtT KrrutHi — «m 
ID DliOSURIK — ssit.1. ivoinrT or crk* ■■ THI DI/IDD IK aoUT, 
lUO or UULIC ICIU—tUlQKB Or UKIO ACId aKD riRl IX nRALTUr 

■IMS— i-Ki«piuTioii la aOQY— OXAUO 4C1d rou>» m t«u 
■HunoK. 

Ik Tain shnll wc seek among aitcient writors, or ov«n 
thoac of mcidcni ditto, for siitisfoctor}' infurmatioc 
itRjwoting tho alteratidiiR of tlie blowl in guut, for 
until recently all that had bwn ddvanctl, thuu^ 
emI>od\'iiig much truth, wna purely spocululive, and 
fiulcd to convince tho mindM of many puthi)l(><;p!(t4 who 
CDdcaTOurc-d to c-xpluin thc^ phonumcim of tho discaso 
by othor than the h}-]K>thesis of thu presence of a 
morbific matter. 

In thU chupU-r it will be my aim to give im KOOOOat 
of tlio present state of our knowledge on this tabjeot, 



IMPOKTAKCE OP PTS STPDV. 



n 



I 



uf tl»c Iu^li<«t im]xirtaiiMi for tho right undurstanding 
of Ui'- iuitli>>l<igy <jf gi>ut, mill fi>r the clcur L'xpltuiu- 
tiiiu of many of the pathogiiuniutiiu s^-mptunis it 
cxlut>it& 

If any portion of the body may bo considerod of 
pamnoont importutioe, it is uadoubtt-dly tbo blood, 
tot thnw^ its agcnc>- all tho phcDoiruma of lif<.> arc 
ucoomptubed ; by its moans tbo dificront purtiuiis uf 
Ihtr aiiinial frame iiro nuuiisht-d, and it is in itsi.4f the 
eeatre of the tooHt imjiortant cban^^- IK'iicc tbo 
Tallin of a cuniful study of its oonipositiuii and 
pnipertkw in tho inveetigation uf tbo naturo uf any 

£■0006. 

As tbo blood reopivcs all the crude noumhmont 
iniraduued into the sj-stcm, previously to its bocfjiuiiig 
a part nt the solid framework, and prcpuR-^ such for 
its dustination ; as it is also the rt^^Ok:ivcr of tho pro- 
dncb of tbo metamorphoees of the tissues ; tboro will 
BOoeoBarily bn found among its constituent raattora to 
be prepaml and made fit for nutritioa ; principles 
■Irasdy perfected; and bcsidctJ tb<<M', various etleto 
raattttra di-stinLxl fur oxcretioR. These latter, in 
bcaltb, exist in tho Uood, only in the mast minute 
triDee. firom the perfection and activity of tho excret- 
ing orgaiM. 

Tbo annexed taMe, exhibiting the composilsoo of 
be^tby blood in tho 1000 faiis will lacililate Uicdear 
floniinbenaoD of the changes which this fluid undcr- 
to genu- 



fi 



Bl-OOn IN OODT. 



rOti)bulinlI3*G 
Clot. ] Hmuntb rO-S I ««»tit''ti>Wll"'f^««r"«l« 

Albumaa . 
&lta: 

Pboaptuitc of Kidk, llmo^ niagnciJa, anil 
Irun 

SulpllAtO of potlUlj 

CUoriUu gf ndiam anil potwaiaig, 

P>U: 

Hupkrine 

Olcina 

Struliao. . . . . . . 

Chulvatnring 

PbiHphiiraleil P*b^ fto. , , . ,, 

rnkDova lubtUiii!!!^ rallolnitnetivemathini, 

wiUi tnMiit vf uTon, ufic uiil, onMitioo, kc 

Wata 

CirboDio acid I dUnlTed in tb< dnld. 



Surnni 

■P If- 

Btkalinc. 



131-0 
70-0 



8-9 



1-3 



Do tho normal constitupntA of the Wood bcoome 
«]t(Tcd in gout, or arc matters naturally pxcremcn- 
tiUous rotaiuod in the fluid, thereby influcndng its 
compixiition? 

The ijlohitlea or red oorpusdes are not neCBBBifly 
altered ; in acute gout tboy may rvmaio in tbo nonul 
proportion, but in many dmmic and asthenic 
tliey are notably diminished, a.'* tbcy would be ta 
weakened and depraved conditions of tlie Imbit nriMng 
from any other cause. In gout ocourrinj; iu painten, 
plumbers, and other workers in lead, it is common to 
find conaderable diminution of the globules ; this ia 
not tho effect of gout, but is dvpcudont on the metallic 



UOHI'<»ITION OF THE HLOOI). 



93 



unpngnattun, fin* une of the oarlicit effects of the 
alMorptuiii of luad inlo the sj-Htciu is to produce 
•namift. 

Tho fibrin unditrgaes the same Tariations oei iu othvr 
influiunatar^' tltMues. When a pationt is Bufteriiig 
from conAidcnilito locul iufliimmation it is iocreafied ia 
quantity, evca to four, Rvv, or six purls in 10(10, the 
ttogmentation boin); in pni^iortioD to the iiitonsity of 
tho idtluinmation ; but in chronic gout it nmy mnuin 
ID it« normal proportion, or l>e only wry dUgbUy 
nised. Tho variation in the Bbrin nppi^rs, tliereforv, 
to have no relation to gout as Aiirh, but to depend 
aimply on the derelopment of inflammation from the 
nnrliid condition of the habit ; it folluwH, th(>rpfun, 
that the blood when drawn from a f^outy putiout may 
exhibit tht* pheuomcna of being butfcd, or buffed and 
flupped, or it may proiii'Dt notliinf; iibnoniiul. 

Tlir leruat in tuA ue«c«8arily ult«Tcd in pbysicul cha- 
racter* ; ibt apecific gntvtty loay romuiii ut the nomiul 
Bgan, and itn colour and oonaastence as in hcnltli : 
itiO, from the reoultn of an cxtcuHtro tiiblo allowing 
the «ei);bt of thin fluid in different diseases, I am of 
opisinn that in gouty cases the mean specific gravity 
i» lowtrr than in meet other affectioiis ; in fact than in 
■n diaeaws with the exception of albuminaria and 
true Kiirbutns. In eaaos of Kut« gout occurring in 
roboAl nubjwtA, the blood does not show thiit pheno- 
■tmoa ; in faiH it occurs ouly in patients who haro 
U>ng luffen^l from it, or in cnsM of wcll-mnrked 
kidney afleulion. Wbrn tnmtiiig uf tho mmUtion of 




9t 



BLOOD IN OOCT. 




the urine in gout, wl- :«1iuII .thow how commoa it is to 
find tract's of uibumcii in tlic auutc. and etill mora 
frequently in the- chronic form of the dicciuo, o«pe- 
eially when aocompaDied with visible deiKwiti) of unto 
of soda ; tlie diminution nf tlie fipocific gravity of tlie 
sorum dopondfl, tlierufuro, partly upon the loss of 
albumen by tbo kidnfiya. In scarcely any case of 
UDCoiDplicated gout hare I observed the weight of the 
siTum below 102;), and the average in chronic cases 
hiu been fi'DHi 1027 to 1028, a little lower than to 
health. I Imvo never found the albumen uf tlie blood 
inorcn^ in gout, although sueh has been uccasionilly 
aasnined on mere hypothetical considcrulionB. The 
variations in amount of the saline matters of the 
serum have not yet been made r subject of special 
ioTcsligation, a remark which applies equally to the 
&tt)' ingredients. 

When;, then, Mhnll we look for the morbid ohftngw, 
seeing the normal constituents aro not ncooHarilyJ 
modified? It i.^ in tiw augmentnliou of thoMj 
principles which cxixt in health in such minute traoot 
as to be detected with ditheulty, that tlie peculiar 
alteration of the blood in tlii.* diM>iLso it* manifested. 

A severe case of gout came under my notice io 
Universitj' College Hospital, in the ituminer «f 1847. 
The patient was a man about forty-one years of age, 
who had for the three previous yeare suiferod from 
«>p«it4^4 fits of this disease, and exhibited eevcTul 
smiJl chalk-stones about the palmar surfaecs of his 
fingers, und a few spots in the ears. At the time of 




niSOOVERY OF mUC ACID IN BLOOD. 



U 



I 



ttdiiiuunon iiiUj tiie huKpital, lie was bibourin^ undor ii 
rcoout acute nttii«k, and many juinte in tbc n^ht hand 
were tnftiuitcd and sutillcn. Froin Mvonil conadcra- 
ti<>iM I wns induced to cxAnitDC his bluijd, mure cspe- 
taaiiy with tho ohjcct uf aMortainiiig whether oris 
veid woM pmicnt ; for this pur{)Osc, thmugh the 
kin<inc.s< of Dr. C. J. B. AViltiam^, under whose caro 
tho jiatieiit was pliicwl, a small amount of the fluid 
wi» prcicurt'd. Tho clot was found to be firm and 
Bonu.>whut huffed : the wruin clear, alkaline in reaction, 
and uf iqwdfic gravity 1028. Fivling asnuxHl that, if 
uric adil were |)iv.«ciit, it would bo in tlio iK.-nua, 
1000 grains uf thut Ituid were dried in a waUtr bath, 
reduced to powder, and boiled with rcotifiixl i<]>int, for 
tlie purpose of removing matters which might intor- 
(oTT u-ith tho separation of llie uric ncid, and after 
beinj; tlku-s exhausted it was treated witli Luiliiig 
du<tiU(<d water. 

When a few drops of the watery solution wcpc 
evap<>rated to dryncsa with nitrio acid, and held 
over the vapour of ammonia, distinct evidtTice of uric 
acid waa afforded by the production of tlio beautiful 
purple tint of mureside or purpuratc of ainuionia; 
and when the i«olution won reduced to a thin ■■'jTup)' 
oonsifltenee, and a few dropi» of hydrochloric acid 
added, and «et a-iide, in a few houm uric acid waa 
deposited in it." ufucd characteristic cntttalliiie form. 

From a second (Quantity of blood drouii soon aiWr 
the first, 1000 grains of serum wcro taken and treated 
in the same manner, except that no hydrodiloric acid 



H 



RLOOn IN OOUT. 



was added. The (Hinci-ntriitoil watery solution iras 
allowod to stnnd for nfinic hmir^ wlii«n voiy namorom 
tuftJi of crystals wcro found <icii(w*it('d on th« adra of 
the vo«sol ftnd «uH\ic« of tlio fluid. Thuw crystals 
WTv pmvcd to diti^st of umlc of !«)da ; tlicy jieldcd 
rhoTiilis of uric lurid on the nddition of hydrochlorio 
ncid, nnd when iticincmtod left an lunli, alkaline >□ n> 
action, soluble in wftt<>r, nnd not aiiHwrring to the t«sts 
ibr potash. 

Tbxm otwervations woiv soon aftorwanb rppcuted 
apoB sercral eases of gDut with unifonn reoulta, and 
publislied in tho Tranftactions of the Mcdico-Chinirgical 
Sodc-ty for 1S48 ; and the following conclusion at that 
time drav,ni, viz., thut " tlie blond in gout always con* 
tains uric a«id in the fonn of iirntc of soda, which salt 
can be nbtaiticd from it in a cpystnlline state." From 
that time up to the prcwnt, a tspace of inorc than 
founeen years, I have luxn in the habit of examining 
the blood in this disease when opportunity has pre- 
sented itself, altogether in moiu than a hundred caaes, 
and the only alteration I should fool disposed to 
make in the above would bo to append tho worda, 
"in ahDonnul quantities;" as I have found that in 
health the merest tracer both of uric acid and urea 
can now and then ho dctoctfid hy very great caro in 
manipulation. 

The results of sci'ornl quanlitatiTO analm-s which I 
made on the blood of gouty patients, in order to deter- 
mine tho amount of uric acid, aro conttuned in Hm 
paper alluded to. 




DRIC ACID-TBE BLOOD tS OOUT. 



W 



I 



I man wboAo histOTv is recorded, 
ari<! Uicid vua Rnt ducorered, 
lOOO groins of the eonini >-id(lcd 0-050 grain of nrio 
Mid. 

In ft second caso Uic snmo quantify of sentm gRTe 
0'025 grain of uric acid. 

In a tliird ease 0*030 grain of nric acid was obtained 
from 1000 grains of sorum. 

In the t)Ior>d nf a fourtli pationt 1000 giaina of 
scrum ^cldfd as much as 0'17o grain of uric add. 

In anotlier case the history of which has bc«a 
detailed in the cliapter on chn^nic gout, 1000 grains 
of the ttenim jHelded 0* 1 1 grain of uric ncid. 

In all theoe determiiuitionH, the ijunutitica obtained 
ircje probably mucli under the actual nmoitnts, as 
ooosidtrablo loss is liable to occnr iiom unavoidable 
caosce. 

The process above described for determining urio 
add requiree considerable time and care, especially if 
any attempt bo made to estimate the quantit)' ; and 
hence, although it is a metliod inoAt desirable to have 
recourse to in inT(«tigating the pathol<^ of gout, yet 
it ta one which cannot bo readily employed in clinical 
mcdwinc. To obi-iate this difficulty I have devised 
another mudu of awertuining the- prcM-iic-L' uf uric iici<t 
in tlic blood, which I have bc«'n inudi in the habit of 
nang clinicidly fur th^' IcL-'t ten yoiir», and with the 
Rmdta of which I hnv<< reo-Mni to lie well ^tisRed ; it 
u KicrmM! a method which CAti be n-adily employed 
by every medical practitioner, and whitih has the 



n 



BLOOD rX OOUT. 



adrantagf! of requiring tho abxtraction of only n minuto 
quflntity nf hlmd, I tiiiv(> iininod tlio proorw tho 
" Uric Acid Throiul Expcrimi'iit," an<l it iw thus jht- 
fonned : — Take from nne to two fluid-drecbmii of the 
fienun of blood, nnd put it iiitn n Rattt'Dcd gliue dinh 
or capsule ; thonr I profnr ftro about three inchcB in 
diameter, and one third of an inch in deptli, whifh can 
h«j readily procured at any glasa-housc ; to this add 
ordinary strong ac^^'tio acid, in the pinpnrtion of 
six minima to cnoh fluid-dmcbm of scrum, which 
causes the pvolutinn of it fi-w btiblilcN of gaa. WHipn 
tho fluids aro well mixed, introduce one or two ulti- 
mato iilires about iin inch in Icnpth, from a piece of 
iinwn.'ilii'd huclcnbiick or olber linen fftliric, which 
Eihcmld bi- di'])rt%''iHl by iiu'iiiih nf n i^iiiall r«)d, lut ii 
pnibo or pniut nf a pi-n('il. Tho gituta ^ould th<-ii b«^ 
put iL-sido in II cool |ilitc(-, until tlie .4(^ruiii is (|uit4> nrl 
and almnst <lry; the mantel-pieee in a room of tlic 
ordinaiy tomperaturo, or a book-caw, answra wry 
Toll, the time vailing from thirty-six to sixty houni, 
dopi*uding on the warmth and drynosa of the almon* , 
pbiTi'. 

Sliould uric Rcid be present in the scrum in quan- 
tities above a ocrtmn wninll amount noticed below, it 
will crywtnllisc, ami during it« cn'Ftnllisntion will be 
attracted to tho thread, and a-wumo forms not onb'ku 
that presented by sugar-candy upon a siring, a» ; 
fihovm in Plate v., fig. !i, a, h. c; when in tho AaA 
fii.'Id under polarised light it bas an oppcamocc 
represeutod in tho woodcut, fig. 13. To obflorrc 



CUKICAL TCOT rUK UBIV AUID. 



W 



* '^'^'•%?:?- 



thia, the i^ASs oontuning tlio dried Aeram shoald bo 

placed under a LLncar inagnif)-iii){ power of about fifty 

or Hxty, procured w'itli ilu 

inoh objcct-gIai« and low 

cyc-picoo, or n aioglo leiis 

uf unc-tnxth uf on indi 

focus nnfiwvis pdrfixtly. 

Tlic urio acid U found in 

thu foim uf rlioaitts, tliu 

niK of Uie crystals varying 

witli the rapidit>' witlt 

which the dryiiiji: of tlio ^'8- '^* 

xeruin has been elTected, and the quantity of uiio acid 

in the blood. To ensure perfect bqcccss. sereral pre* 

cautions are nfioessary. 

1. the glasses should be broad and flat; vatidi- 
glasses of the ordinary kind are nut suitablt?, being too 
small, allowing the Huid to be fiequently spilt, and 
also too much curved, cauinng the film of partially 
dried semm to curl np and feplit. 

2. The aoetic a«d should bo neither very strong 
nor too weak. The gloctoi acid forms a gclatinoos 
compound with the albumen of the scrum, producing 
flakes ; and very weak acid adds unneoossarily to the 
bulk of the fluid. By experience I find the ordinary 
strong oeotio add (about i^) well suited fur the 
experiment. 



* Vif. \i rvpTOcnti a Bbn «r Iknad vith rliombt «r ario aoid 
>dlwriin to U, u Man snder |«luuo] Ugbt with * Uncu m*(siJ'jiag 
(OwwtfM^ hntd with kD inoh otjM^iliM ud lo* ervpitcc 

■ a 




IDO 



liUHiU IS (xnrT. 



y. The character and quuhtj- of tho thread on- of 
eome moment. Very Rmoutli aubetances, us hoira <>t 
fine wire, but imperfectly attract the ciystiils ; if tho 
number or length of the fibres he too great, and the 
unount of uric acid §mal], the crystals hccuiuo much 
Muttcri'd, and therefore but few uppcnr in tlic field of 
tho micruscopo. Tho glairs should not he disturbed 
during the diyiug of the iktuid, or tho crj'stalR may 
become detnched from tlic thn;ud. 

4. Some iittcntion to tciupcrutiire is ueccseary; if 
the scrum be cvaporutt-d iit a high tcmjieraturo, iibove 
75" Fahrpn licit for cxrimjile, Uio drying may take plaea 
too rapidly to allow orystulU^atiun ; the temperature 
of an ordinary sitting-room answers well fur the pur- 
pose ; the glass should bu protected from dust. 

fi. If tlio scrum bo allowed to di^ too much befbra , 
the examination takes jilace, tho surface hceomes 
covered with a vhito etllore-sccnce consisting of feathery 
phosphates which may obscure the thread, and which 
are represented in Plate vi-, fig. 4, c; they can be 
removed by the addition of a fow drops of water 
before plneing the gloss uuder tlte microscope ; some- 
times oTcr'drjing causes the film to hceomo cracked 
or fissured throughout, as well as covered with tho 
phosphatio effloresccnec. 

6. It is well, when practicable, to put up two or 
more glassed with the same scrum. 

7. The hlood should be recently drawn, or at least 
no ohange should bo allowed to take pliu-c in it U'foro 
the esperimeat is made, as uiic acid when iu contact 




CLIKICAL TEST FOB UBIC ACID. 101 

with albunuDoos principlee is liable rniiidly tu undci;g<) 
deoompoedtion. 

Jieffrtv of DcJicttfy of the ahoee Teat for Uric Add. — 
Tlic WTtun of Lcultliy bltMjd, iw iJbo of patients niifforing 
frwn tho tnnjurity of dijwaso«, ultliough usually con- 
laining a traoe of urio acid, gives no indioatioii of its 
pnomce by tko " uric acid thread experiment ;" and 
tbe absence of extreme delicac>' ia Lhis test is a most 
valuable propertj', I have endi-avoured to ascriiiun, 
bjr a series of vxiKrimcuts, Uit; <|uiintitio» of uric acid 
wluch most oxiMt iu Itlood bt-furu it^e pn'^-uue cim bo 
tbiw dvnwmtntMl,' and for tliL-> ])urpi)!4o liavc addi-d 
inato of Boda, in ocrtain definite projwrtions, to the 
Kniin of blood token from a healthy subject. 



L Shvd. with tie kddltiati of uio waA \ .,..., 

i. A. pop^iicB rf 0010 v^ i- «""."" "^'*'''"'' "' ■^' 



t. nil nil. oeaUltloB O-OSO gt*l& tn Uw I M cr]*tal* of urio aM 
lOM gnias . . j clcpoali«>I. 

2. r<i ■III. ««Ulai^ (I-U2S p-*iu in Ihi i (an tvo or thiaa orjvuU 
lOfli) gnim i oa tiutid. 

4. Bir«B. anolriniai t-OIO snia ip lb* I 

lUOOsmbi. |(.«»ft-«j*l.. 

& SmM, aM»lnh« 0-OtO pmla in Uu i 

ItOOfHtM j (.« M»or»l efjtuta. 

4 StroM, MslaioiDf 04(0 paia in tba i ■ iD»l«nto •giriiikUDg af 
tOM ralM I «r7rt^ 9D Ibe thnnJ. 

T. faiiw. wtainlac OMO |nuB in the i Ibe Ihraul \m.\j (nr\j 
IMO piiM ( eonnil <rllh erjrt^. 



*lfadi*»-CUnttM TruiaKilxmi, ml. mrii. 





loa . ni.0OD IN GOUT. 

$. tlBruiu, couUlulu; O'OSO eruD in U» i 'try nnmcroisB ajwtait ca 
lOOOjraiiK I llitcml, 

iabaudniicc of eiT*tall^ 
man tb>n (umUt tauui 

ItUroul oani|ilDt*l7 eonntl 
with orle idd. u>il eu- 
meroiM crjnlal* nautti 
tbraugbDnl ■eran. 



From tliis it appears, that an amount of uric ncid 
equal to at leatt 0025 grain in tin; 1000 gnun.i of 
•cnun, tD addition to the tmcc rxisting in health, u 
ivquirod before the " tliiv-ud experiment " gives indi- 
cnttoii of itn pri<i<eneo, and hunee the npiK-Arancc of 
uric acid on the thn^iid i» completi- e\'idcnce of an 
abnormal quantity in the blood. In several experi- 
ments on the bluod in psut and albuminuria, when 
qiiuntitutivc detcrmiuutions were made, the ninotint of 
uriu aeid in the 1000 gnuns of scrum vaa foand to 
varj- from 0'046 to 0"175 graia. 

Cfiariffft in ffic Uric Acid during decomponfion of the 
Semm. — When cnunicniting the precautious whicli 
shoidd be observed in the employment of the threud 
test, it was stated that tecently dniwn blood should bo 
made use of; the importane** of this prociiiitiou will 
boSM-n from tho followiug observations, which wero 
at first tho cause of some perplexity. Having ascer- 
tained the presence of uric stcid in the blood iu several 
coses, and put aside tho serum, I found, on repeating 
tho experiment, tluit uu indication of urie acid could 



■ 



CUmCAI. TEST fOK UBIC ACID. 



IM 



I 



In dueovored ; thu happened most frcqiti>ntly dnriug 
the sumniiT montlu. Chi closer cxaitiiiiaiion I ascer* 
taioctl tliut the M.-nim had unilcrgoao riigfat di-oom- 
fumtiao ; tbii gave mo it clutf to tbo cxplaoatioit of 
the [ibdoamenoa, namvl}-. that the ario add in the 
blood iiadoqjocs a qx-cuie of fcrmcDtation, mid is 
dceompoH>d whvnoviT the tilbuniiiKiiis porttuti becomes 
•Iturod. In order la vvnfy thU, tlio fulluwiiiff cxperi- 
otcnt was nuido uid rtp<.3itvd sovorul tiincs witJi 
anUbna result. 

Unte i>f Eoda was dutmlvod in serum iii the pro- 
piirtioQ of from 0*10 grain to 0''M gniin to tlio 
1000 gniiu, utd tho fluid allowed to become putrid, 
■sail |>»rtioa8 being put into the ]L^as§cs from dmo to 
tiiiii- ; it was liniad that the crj-stals, although very 
Dixiu<-n>ufi at first, bocamc fower in number and soon 
diMppeAred alUjgethfUT, proving the urio acid to have 
liccn gradually destroyed, and tlius showing tlie ex* 
tnmto inportonco of tmng fresh 8cnim, more eaj>ecially 
in wunn weather. 

I have made aomo experimentA in order to disco\-cr 
tbe changes which uric add andogocc when sulji-ctcd 
to meb decomposition. 

It u a weU-knuwn fiict that whoti exjiowd to the 
action of oortoin uxidiang ogonU, m the puce-colt>uivd 
uzide of lead, oiic acid h broken up into osidio iM-td, 
urtnt and allantoin, and wlien ttie oxide is in exi'css 
tbe uxaUe acid is furtlKT oxidised and oitivcrti'd 
into oarbooic acid ; thin fiiet led me to try wlii-tlicr 
uzoliu add may nut bo fifnocd in Ihu blood from a 





BLOOD IN OOUT. 

change in the uric acid. For tlus purpose I modo 
doily olKH-rvntions on serum rich in tirio add, mid hud 
endcni^, during its docontpomtion, of the furniittion uf 
oxnlio ncid, the occurrence of octahedrRl ory«tuls of 
ozolftto of lime. I Imvo alio c-vniioriihHl Uio scrum 
whoii deoomiKwitioH wa.s tnkinj; pliioc, ami obtAincd 
ci^Tstals of uxalutc of limo. To niuko tbo oxpt'rimi-nt 
iDurc coDclunTC, I haro tolct^ serum of blood free 
from lui tippa'ciublc amount of uric ncid, divided it 
into two part.*, to one portion have added urate of 
soda, and then allowed both to decompose; it was 
found timt ill the scrum to which the urate had Imjch 
added, octahedral cr^-stols of oxalate of limo wore 
formed, but not in that freu from uric acid. The 
microfwopic examinations w-ere made with amplifjing 
powers of 200 to 400 linear. Much further investi- 
gation into this Eubjcct is required, but enough has 
been done to show that the study of these changes 
is not without interest to the pathologist, for there 
can be little doubt that oxolio acid is formed in 
the ftiiimid body, not, im formerly supposed, from the 
oxidation of sficcbnrinc matters, but from tho decom- 
position of urio acid. 

As before stated, I have made numerous detcimi- 
nations of the blood in cases of gout ; in the subj<tined 
Table some account of forty-seven of these will be 
found, and a poruwU of them cannot fail to convince 
the reader that tho articular alfccti<)n under which 
the patients suffered was truly characteristic of the 
disease. Since the Table wa^ coustructed, I have had 



CONDITION OP BLOOD IN GOXJT. 



lOS 



nnmerons opportunities of coofinniiig the resulta 
themn contained, but those already tabulated are 
qnite Bo£Sciont to prove my original statement, that 
Um bhod in gout it inmriaily rich in urie add.. 



■1 


■■■HH 


■ 


^ llllt 


BIjOOD in COIT. 


3 


w 


TiTii-a, EAiiiliHg Ihc Tfitiora and Ssmptomi o/4T C<ua of 1 

iM<wrf. 1 


^H Kurd. 


4 


OooniaUau. 


EbtilUolUf* 




^1 W 


38 


Quritter, 


Dmnk in nob 


rntliur 1i:id PrrUj gDoJ. KotMmik. 1 


^H 




DCauiouanj' 


^iu anil Ixicr 


K'liitcFrrhrn- Pinoturwl |PinirocGvo | 


^^B 




iDiuiciun. 


or i«rtcr. 


uiatimn. Mo^ 


liU about 1 mil 1 


^^H 




Hm ocnr 




iliDc'i fnther 


■ii rcai* ' marknL f 


^^^ 




tuul 




^jiit, nud all 


a«o; ilDca 


M 


1 




lead mUd. 




luutlivr'a 

AlHn owu 

bi'itlitr, 

(See bi'low.) 


IbmialToatMl 

■1 JTb iiria nt 

diaWM. 


1 


^1 


43 


Pttlattr 


Dttiik 


AplArvntlj (ioacl.e^<K]il 


Kunarona. 


^^^L^^ 




(Hdiutt). 


fpBoly, r"' 


harvdLtU7 wbtji aaffvr- 


FlntMtaefc 


^^^^^K 






ter Bud gin. 


fiKiii blhor, lug Xma, 


vIvTvafaata 


^^^^^H 






Not in gical 


wbn. hii<r- goni or Itad 


•iae«t flrai 


^^^^^^ 






(iron; ollcu 


i-vcr, dii^cl 


Rulid. 


in nnklv. 


^^H^ 






tit |j1uUuI 


•ln'n ]*■ 




DOKt in paat 


^^^ 






imtlw 


tisul wu 




bOB. 








diiir- 


jonng. 






J. E. 


SI 


SioiuaMMi. 


Not lUtcd. 


Kol f laud. 


GmkL 


Kumerao*. 

Y\n\ aUaok 

oooantJ 

aiuoainaoa* 
)uut uf (bol- 


^1 T. p. 


40 


Wia*- 


HMdraak 


FMber and 


PreMy good. 


Kumwraa. , 


■ 




OMpff. 


fnlljraf 


grudTnthsr 
DD Mtnii *ldc 




P-ratabool 

ten TMn 

•ioea, la bM 










bad goul. and 




^^H 








lathtr bnd 




auilaaUN. 


^^H 








ohntktUiKa. 






^1 


38 


Bnwcr'* 


Uu drutik 


P&tbtr's 


Qnod io 


Not knavD; 


1 




Iln. 


T<iry fr«.'lr, 
ehirflj por- 
ter; (oms 
gin. 


brothfi bail 
gvnt- 


general. 


uarDCTWia. 

Ahratto* 

fcan ■loM 
bad Biat 
attack, ooB- , 
eaeltofecA. J 


C.P. 


3fi 


TainUr. 


TtiBptnUi 


SMiiiulcr 


pMUy BAod. 


Se«ondat- 


k 






alpBl two 


W.P.,cu«l,>mpt rroioi'toek. Rni. 




ILLtrSTBATIVR VABtSik 



Aiiitular Afftttiam, in K^iA Vrit Atid imi ftuaU m lie 
Oaitt 1^ gtmimt 0ml. 



or. 



»iKb drink. 

isf bfbrt 

(fWHnt 

■lUdk. 









(Aru 
liruBKht on 
mitwk* hj 

r«rt wU«. 

Rom 
ainincd. 



ftfioplam* dnrim Altuk. 



OoanMnotd iu boll n( Uti gmi 
M* ; aflar four i>r Sre dajn, kn«^ 
«IbttW*,1iuid*,&iigtn,»n4 ItftuiUv 
iJiB bfl iiittaear|»l >a J pliolaniMl 
juial*«IIM*il. rUtingon t i w «Br>. 
FdIm n, bud ud full ; tonpic 
•ligbtl; tend j mom tMiM ; dt- 
r«*lli of nnU of ndk on oiani 
■ttiheoaf kft ladax Sag(*. iCoton 



S<nck)i]r 



CeouwDMl In Utt kaM, tlun 
donum i41t(l bMd, ri(bt h*nd, ud 
botb feit and uklci^ nnnlljmntiof 
handi Pilling on praMore. PoIm 
B2, nthor liud ; t»ngM aligbtljr 
fnmtl ; kppettla pm^good. Dc- 
pults In botb can. Ho «th*r dc- 
fodia M«n. Ho pMnuovnt lulwUtf 
tojoinU. 

ASnlion<d'bkDd).aiikl«^kBOMt 
Up*. Polie 80. DgporiU in «n ; 
will liulo DadaJw is kiesDfflMU 
MUOfta. 



CommtoMdlB fcnM^ tin dbo*, 8tnnnaonUlntditt«- 

ud MMll joinM «f bMdii. Fit- (Idenhbquotitjurnric 

tJDE on pTMnr*. Piln 74. Ko xid. 
dqudti of wale of nd* notieod. 



BIMa of Blood. 



Clot Rnn ; Mruia nl' 
luliuo: ip. gr. in-JU-4 
•( C$° P. ; mooli nrle 
■dd hj ttiiMid npftt- 
meBlt. 



Glut illglillr Ivlfnl 
■nd QouUiuUd 1 Hraio 
■lluJint; ap. vr. lOSSO 
at flO* F. ! •IinndMM of 
nrid Ifid. Btitttr JIM 
tmm iabncd junt ; no 
tranof otieuid. Mw- 
Mr jlaH fron •Mnmw 
|*ro a Biod«r»U uoomt 
of srioMU. 

DrioMid in Mran. 



Bolb Ibtt, knM*,bli>s munjidnlo 
of kand^ ud in gnat 10*. nltlsg 
BB pnMan. fub* HO. No (bint. 
Uinnto namiioM of aiM« of ooib 
in loft tar. I^igc Mmi-Bnid «oI- 
IcctioE in Ml IttA vt oraaiBj walm 
ofioda; wnud«pa«IlilM«*ri^ 
Iiltla Coeor. 

Cflianfaeed iv»dapaA«r iojair, 
in Idl olbo* and tof/in ; aAir- 



Ctot trm, Imfled and 
tunrol; wran ftlkalinc; 
<p. (T. 1039-0 al U* 
V. i abusdaaso of arid 
acid. BUltrji<tii from 
iaaasod pari gav* no 
lneoofBri«*^ Siii- 
UtJIhU fiWD aokle. a 
lev MTOla]* of uric acid, 

ObA nonnali "(niTO 
alkaliM; ifi p. lOatiS 



^r yHH 


^ 


^ 108 BLOOD IN GOn. 


^^1 Hue*. , 


1 

f DoOupsUtol. 


HaUUafLlfe 


Bendltory 


Oimonlitau 
tJ-awltb. 


Xoofatlaeks. 


^^^_ 




triata of por- 


ifae 


plWCBt 
dlaauR 


onafBwaad 


^^^^^H 




ter dftiljf ; 


brMliw of 


aqwrtw 


^^^^^H 




fonnorlji 


lh«prMMl 




■inoot VOB' 


^^^^^H 




tookiiilnta 


paUtnt, 




DieDcal Io 


^V 




ktu. 






toft root. 


^K 5 


1 FMTin. 


Hu olnyi 


Falhw had 


QDud. 


Bubod DQ- 


^^H 




bMo afrM 


If out. aliw 




DKiniu* at- 


^^H 




drinker >if 


OHO brotber. 




»cki. Pint 


1 




beer and jiin. 






letK MTm 
or olgbt 

roan liiMo; 

data Bot m- 
■Minbfr 

whcllicr tho 

{TtaltooTU 
^laS; af • 

ModlglMt 
toca haro 

bMoin icDiD 
attADka. 


J. n. * 


S Falilinn furl iDtomp*' 


Fnllitt hnJ 


(itwi], except 


NnmaraiM. 




muiT;ou«,|nt«. Dnuk 


l^iul, u1«o 


liuaij'. 


Pintabost 




farmcrl; > 


mam beer 


bruUlare. 




fonilMiD 




p<M( b<7. 


and idn. 
Oood diet. 






<n right 
gioal totb 


t). H, 


S WhMl- 


RmuIat. 


Nol knomn. 


Pntlf good. 


lUiat tha 


1 


wrifbt. 




TBTj d«af 
iudeod.) 




twclftL 
Pirn attaek 
■BballorkA 

Crwtto^ 
Bwrt is light 

iakrn 

joiato*lM> 


^ J. Z, 4 


3 SuUnDM, 


l.WiJil fra»l)r, 


Kanv. 


Good. 


Abool IhiDl 


&. 


formurlf > 


Iwth in mt* 






BtWk. 




•oldier. 


ins and 
driDking. 






TVentJ 

•tneig, *<aell- 

isgof ball 

nrgmttMi 












noxt aUMk 


■. 


_, 



ILLUSTKATIVK CASES. 



IU& 



i bt^^tut 




M»U«k«r» 



Brisk. 



lljrDploiu dgriug AttMlc 



WBid* liMh ftet md rig>it kiie*. Bud 
rtshl iaAn ioKir. Piltiuf i>n |jr«a' 
mte. roU* Km. Tm^uc fairwh 
IkinL Plnid from ri|bl iiidti tingtr 
(aiiUle j^iatl obtainail b; pnui'tutn. 
aUkf from ante of lod* (four <lii;i 
■iWtf ti W isflAmed^ ; Oonf^retiuiu 
•ItarvMd* anNared no righl tar, 
••d la Un mudle Idmt. 

Aboal fcc1j-«)|bt boam tftai iu- 
imrj tbt donoD of rSgbt l)nn<l kniJ 
fo«4, aad UA ilbev, «p«D vliich bt 
bU. btouia ■Bailed. nuin| rni 
pnnan. Tvit SO, full, haid : 
ana lUiit; appttiw good. Mo 
il«r««U U Draka. 



SMMdC Bluod. 



AaklM ud fatt eUcil]' aflcMid. 
nulnf baal; mi prMaota. Oi» Umd 
tim miA avalko : laogua eltan ; 
apiMUto g»i ; BU tklnL FoIm 71, 
aM naiMinc- Kodulg* i4 unw af 
•*■!■«■ tolh tan. 

OrcallontMbaAvUdi Ifftkon 
■D^llri (aUtat la* •racma of bMh 
lapL KlM »S. AppttiU ctod. Kg 
iapadlatJ antecf acda. 



I rtfhl Xnt*, then 
Wn (kMldti^ bank Irft kD<«, 
Uta U botb mat loca bnama ini' 
|MaUd. I>nb( 110, lalbcrkardi 
uagaa vhHtk fnrred. Htlina on 
liiwupB. Ha dmaba of <mu »( 
Mda H aay fan *f bvijr. 



It 50* F. ; abnniliincD or 
drill acid. Blitirr jliiid 
ftam cbst, ■ mudcnw 
amonnt of nria iwld. 



CJot (IlKbtly bnflM : 
ruiruiu nlkstinn; *)>. gr. 
lOiU 01 nl 6s"y. A 
(ooii jiprinkliuii of v.tw- 
Mid oil Ihrtad. 



<'liit noniiAl i wniiit 
klkblinri a)! nr. lOSfl'd 
at «7' P. Abunduce of 
utie uid by thread u- 
parlaicDt. 

Clot nemal : wnim 
■Ikalioa; ap, gr. 19SS-0 
at S&* P. aiB«d>nMa 
(prinUing of arid awd 
oD Uiraad. 



CIM normal ; 
alkaline ; *f. ft- 10»'0 
al OO* V. A ttw ay- 
Uli of Dfle aaid. SUm- 
ttrfiaid p" ciTtlal* rf 
uriruid. Lli^trtitii 
tniB inmnrt'l kiic^ aa 
aiyiuU <f arie acid. 





■ 


■ 


^^^^110 BLOOD IN GOUT. 


1 


^^m Kasi*. 


i 


UooupaUwi. 


lUbitiari.Iti 


tlimtlUry 

Pradl>;w*[Uaa. 


OvDanJ alata 
oIHadUk 


XfufalUda. 1 










• 




eoinnicncni 

aln lngn«t 

too. 


^^^ 


M 


TrtT^lir. 


Temp«nt» 

Imc hu 
drnnti mttoh 

porWr; bitif 


Not ktiDvu. 


QouiL 


About tix\k 
uuek. yiM 

OOUfiDMl M 

riftil K'VO'I 








k gslloii or 




'tii«,l«o7(«n 








more per 




.HBce. fMmr 








iIImu. 




JolDttaAtf 

■OlMUd. 


U. H, 


SS 


Oib-drl«v 




So gmt or 


Oood.exMpt' Numimai. 






mnl 




fhBQUfttlUQ 


goal. Fim atudl 






propriolor. 




ft«ai tUkw 

Or iDotbar ; 

but ui)i:livi 

>nd luiiUion 

bnlb •uloi 


thirtjtrMTi 
■eo.ln(cMi 
Mconda^ 
MoklnbtU 
ofbotlpol 
uws. KMca 










Bubjcot to 










Suul. 


D"laff*rtMl 
satil tw» 










■ 


f eui •ine* : 














uulluljor 














np|icT ulrc 














nluri. 


J. (L 


ai 


rbtnnfotU- 


Ltrodwcll; 


None. 


(}ood.*i«^t Pint ■.Uack 






mkkar. 


dmik mo- 




ooouriiinal jaf|:ai)taboat 
font, >iiil iiiaijTBUa 








danUly of 










bocr uiiB 




iMterlj 


■uon, i 








■DUs gin, 




•QinQ mUfH' 


1 


• 










mlaam. 


d 


c, n. 


40 


CuanhTiiftn. 


JTn* Unink 


Nous, 


Good.UNpt 


NamerniuL 1 


i 




L»i Umt 


(nslj of 1 


nlgcct to jKnt aUack 



^BBHHIBIHH^^B^^^^H 


^^^^^H lIXnimtATtVE CASES. Ill ^H 


^^M«f. 




GUIaofmBOd, ^^M 


^ 




Soeonil bltwliiig liro daja ^^H 






tiler : Clut n^t baBcd, ^^M 


^^H 




or cni'peil ; Krnni klks- ^^| 


^^H 




line; ip. gr, 1027 1 at ^H 


^^H 


* 


OS* V. Vntty gnod ^H 


^^H 


qiMsUl)' of urio Mid. ^^| 
Tbinl binding dght ^^H 


^^B 




^^1 




daj* after : aot Atid ^^H 


^^^ 




SMoow «<«t ; igruiii ^^| 


^^^^^^K^ 




pre ■ modenita tmouiiL ^^H 


1^ 




«f urio Mid bjr uric uxid ^^H 
thrtad raperlmeut, ^^H 


rirmm$m.3 




Bcmm nra abundnnca ^^H 
of nrieadd. ^^| 


LjMthtoMU 


Mtbal,riKktkne(, aDdhauJi U(l 


Hts£r 


riMToUtr uhI liBiuL PlttiaB on 
liwiiiw. PbIm li>gv banl ; loacM 
vMkvlWmd. NuilepsiitiiufuiMii. 


1 


IBl 


AffMtionciflpfltJtjuw, wriit,ftnd 


Out bnflbd, flm : w- ^^| 


•tfM<L 


ttoiffi i<aat nMnilci flngw. Kn; ram «lk>IInti qi. fr. ^^| 


^^_ 


dffvdlMfvMim. TuluSIt; lui>t|iic 


lOSG-ne at d4* P, Fiviif ^^H 


p 


wnd; BO k|i|«tlta. Flttlni iw 


■nod *|iruik1iiijt rif urii* ^^H 
ai7id ij Lhitad npm- ^^H 
DWDb ^^1 


^BiHAM' 


Vint BzaaJulloo of Uo«d Mm* 


Rnt wamiDBtioa : ^^| 


^^BWH*«a 


UllU llin* hrorr llii' j 'inia bMUnn 


Clol iHinuI ; KTVU >!• ^^H 


^^En ■■■• 


llli«>L P*UiMUi*D*u8«riDgritaD 


kalidv; iji. ci. ItMI'O ^^| 


I jfcw* 


«hM» ajTMiilom mJ »K^l aUam. 


■160* P. Agiudqwa. ^^H 
Cit^ of urio and ; UirMd ^^H 
(ttiililnl villi orr>^l*> ^^1 


■^* 


wH**»'TI^"' '"*■ PnnticaluHL 


^^H 


Ikviighl KTist t<v >sd kn(« wrre 


Scrund aiaiDioalioB ! ^^H 


^^B 


■ftrtwL FHtint an iifiiii*. JUA 


CUrt oomal ; nrUB •!• ^^| 


^^1 


attMlwriB, p»<hallj Nwmiiii to 


kalin.; tp. cr. 1033-4 ^H 


^^r 


■ ■«« ti«e<; 


at fltf* P. A ntj kw ^^M 
ra^alnli ti oris acU. ^^H 






a«>w- 


OiSMKicd tUitcCB aeelu bcliKV 


Tint cxamlnatMS ; ^^M 




•Jmiiita^tlwurartlttlljNMVMDl: Clol lra>. trtilMi w ^^H 





^^^^^ 118 BW>OD IS GOUT. 1 


^^1 Run*. 


1 


Omhp»Uob. |tl»Mt«ofUfi> j.™i„,k«i2oi) 


ef llMlth. 


Xc of atUck*, 1 






rtan B «itb-ib«arasdgiD. 




KttMk* Tike 


■bout 1 






nwif 






Lbe jJicMot. t<rBair7(ni« | 














■laoe iDrifbl 














i;rMtb*BDil 










* 




iBfUtp orilj. 












ttMunil M- 














tuk.iixtean 














jtan riue^ 














ioMiM 














put. TUnt 














twtlte jMra 














kb(« Id l«n 














|r«tt«a. b 














•atatqaigl 
ottadokiMM 














and eltmi. 














Attack! 














tT«dull7 














lnrtiMiUEin 














frwjufncj, 


^g 


uo 


Exaiator. 


Drink > 
(tvcly. 


Nouv, 


Qati. 


Pniirtli Bl- 
Uck. Pirrt, 

OomiDDDC«l 

Id ri(tbl 
Crol to«L 


V. w. 


*7 


Qrntltinaii't 


UTadprttlf 


Kano 


PNttTSDOd. 


ADmaroov. 






Krr&ut. 


frMlf. 


olwrlj Jl«- 


utMpl fhnci 


EhItm- 








Diuk bctr 


«)TgrabI«. 


goat. 


tjwlu««gu- 








obieflj'. 






iRMocd in 
SmItM. 


h ... 


se 


Hubctntor 


Dnnk vcrj 


Naoo dll- 


PrrttYBood 


ITarngmu, 1 


■ 




■ long tinnj.ltwljnftiftti lluctij tl<i- 'nnUltlioUit 


J 


■ 




ft brrwtr'j 


uid uii), 


«a««ralil(i. 


ftv jMia. 


I 


1 




dnjiuaii. 








d 


U.C. 


so 


Tndwiuu, 


Dnuik fnw- 
I7, iMar, Al^ 


Kot knoiTD. 


Qvnil, until 
gout ■!>- 
pnrod. 


niiu indMil- 

1 



lU-CSTKATPTE CASES. 



lis 




^wifUat dnrini AtUck- 



far Ibnc nskB ba* k«pt his bcii. 
IIuiil^ knurklM, knM«, fral, and 
•kouUen •flcctol. Polw 72, fhll, 
bMiL KadiiBntaor urate efKHl*. 
Til* tnl tiMuUiUXoa •' Uw blood 
wu mil* dnrtug MrllodlalnrlonH 
of UiaaraUn; lIe«a«d«lioi tha 
uliut had i«!n in )i>iut>, fcol no 



aM.iuii«, 



mimtmiiiUL 



ItaW 



DMSamcf >*A irrlM, btml, maU- 
oknal*aJ wvtral |itial>ng*«l jniiiU, 
WHt ivtlliug tt right uda of facu. 
nttiu «f f«to «> praHora. PoIh 
79> R«dmwitaaontoof MiUiii 
■ar t**f of wdf. 

Wlni of (ng*n, vriiit, «IImv, 
■ad Ao«ldM of l*fl lid* ; tlien 
MW» M right lid* i loh ijrail tt*^ 
■%M koM. fnlM 101, nU»r full 
aad ibwp. Snoe IbiM, mocl*nM 
kppelil*. ritUoKaD pnmu*. Dn- 
qaMutian cf «atiott> K« dtpoiU 
•ir«r«M tttodt. 

Left Iwnd ud »Tm, mm) knni, 

IN j/m^trt. Snwnl —all dejMU 
af uau of *m1> In on ; ami nueb 
dkMtiDO «f MuU j«ioU of l(«l anJ 



•laUarahMML 



(Dm; ip. gr. lOSS'O U. 
01* P. No ufie uiil 
fiiuud lij thr«*il axp«ri- 

rnoDt. 

SxMiiil «mu!nation : 
Clnt nocBiiil ; urutu al- 
kalini); up. irr. 1 03* -8 
•t 6S' P. A nindtiBle 
amount of an« MiiL 



rnwnt tItaA ehirtj In hml ; 
iliUrian, btat of knJ, kr. Mnujr 
•if Um Mailer joinU of Itet k&d 
kad* nuk iDrttctel. H«diniiKt 
dir«dtn«fwM««. 



Got ba9(d, Aid ; M- 
mm dou', likalioa; uiio 
uld throkil ix{«iiment 
fnts abuDilura of urk 

■fid. 

Semmi ga»c by oric 
odd thread upriiiaml 
uric aelil on Ihnad : ■•• 
luiu of bhiol from loin* 
by mppint pu* alw ibe 
•aiDI. 



CJot not Iniffed ; •nun 
ckv, alkuliii* ; iii. gr. 
IOjT'3aiai*F.;ani:ici>l 
ibrtad oxponnialt gava 
math vrlo aold «D tbmiL 
Aboal 0-07 palB «ol- 

lOaO irsin* vt wnm. 

Blood hj enppltc ban 
tolu* 1 dot firm 1 -ram 
d«r;»p,gT. lOWlat 
7D* P. : Bric add (hfwl 
oximiniMit glT« I 
daaMi/niiea^liL 



^^■~ 




1 


■ 


H 


^^H 


^^^^^^^ 




l^HHH 


^^^^^ tI4 


BLOOD IS GOUT. 


] 


^^^^H 


i 

< 
S3 


0«rUp«li(]IV 


HolfiUeFUli) 


HandtlMT 

F»aL>|HMUuu 


of IlHltll. 


X«ofutaJ 


^^^1 


Oiok. 


BKVfnrh 


Kone 


tiooJ •xctpt 


AlmoAlJ 


^^^^^H 






or meat : 


kUDWD. 


wbaa goal}. nnmeniliB 


^^^H 






baa drunl 




Pint oc9 


^^^^^^m 






pnUT fnoly 
ItMlBtMa- 






DMDBM ! 

tMib 


m 






PNMIL 




• 


tvnViN 
■law. I 
•ometb 
lb«<liaei 
aibtk* 
great to 


^^^^^H 














^^^1 














^^^H 














^^^^H 






• 








^^H 














^^^H 














^^H 


Jl 


Cklimaa Tor 


Drink! 


None. 


Hod }xtan 


About (li; 


■ 




luMjij f«ar>, 


froelj of 

beer, mme 

■plriu. 




pnacDt 
aflketian. 


baa kid 
joint tttrr- 
lion wltbou 
fcrtr. I 


^^H 


S! 


Friatvr. 


B«for« 


Nuns 


ttooJ DDtll 


VuT BUM 


^^^^^H 






hiring goiit. 


known 1 bat 


ruortvm rona. FIi« 


^^^^^H 






dnak mlliei 


una jnnnjcr 


fcani «iiiM-' aUwk is 


^^^^^H 






freeljnfg'n. 


biotlm bat 




ri^t gnat 


^^^^^H 






wme beor ; 


gpnL 




(oa, abont 


I 






Urtd well. 






1««1t» j«ar 

tUa«ka}«a 
aft«r, IB 
errat Id* 

tlvo, ^t^ 
ttUcmitiM 

lATCDOt 

bcmaftdc 


L 






) 




fcr mora 

M 




ILHrSTBATlVE CASES. 



Ill 



OuMoC 



VoDe 



C J uH i toiw dmtac AtMb 



Thia Mll«at Iiw h^ M diSgrcM 
timci ^I Ibo Jnlata of the b»lj 
Mutely InluDcd, ninetiffla Um 
lufir, wmMimt* ih« uiaTlcT, diitSf 
•flMcd in tha klteok. Thtra la 
•Itij* mooli pUing oa prMnra. 
Tha pabe dorini acoWaUaitki ba- 
eomta qnuk and biai. Kcdulca «f 
anUofaolatabalhtan; udafaalk 
aiMM OB muj farU «f btdf, both 
oppnand lower MtrMnilln. 9oine> 
tUata diMharjB o( tliii unit, uJ 
bmatioa of* lw MiM take pfainL 



nonrallfnrDfjiiarta. SpnpMHa 
■■h{eati*a Muy. AppriHari<^ "<■ 
AIM. Maa 79. Oomidaiaa «f 
palni la Jtinta. and illffwaa is 
■alLtng, vbleb ho bia had •etcnl 
mtMlu. 
lloiSMA AliniriDntba««,dlir«Ttn(Jobla 
for an; c«t aSwud, aatDattnat sraily an loft- 

Bihar. Onatlow,aiKlaM*lt«rjoiBU 
tt fcgwi, a* w«il M hirfa jaisla 
TMlMt oatMtd irith «««ontioiu of 
nnlaofaada: Baajlacan; maiii 
trippbd. 
: 



BbteaflUool. 



CM haiU, and 
■lifbllf r<pp*il; aarun 
clear, alkalin* : f, ar. 
102712 M W* P. 1^ 
ntioadd thnad axpori- 
nwat • oMiiidcnbia 
amonat «l ana iH waa 
abiMocd. 



Blocd hfenppiag tnm 
loiaa; amnn altw, al- 
haBoa; ap. p. iOitO 
•t 53* F. Cric Kid 
thnad MpniniMit lart 
atnmduiM <i nrio add. 

Oot firm and iart^ ; 
acmm elisr. ilkalinc ; 

Sir. loatt-i at CU* F. 
uric icid Ibraai «X- 

pariiDcul aa alfsadMea 
of nrio acid; tram 1000 
pwn* 4*01 (nun «tl- 

Clot not tniBM, sat 
Ttf]t AfH ; aanm alh»- 
I'uM ; ap. p. 1027'4 al 
03* P. A nodantfl 
aaouM of Bile a«iiL 

Harth. 16S«.-nAf«ta 
aUafk : dpt oqniad aail 
hafled i Hran alkaliM ; 
.p. p. H'2fi-1 at or P. 
Abandaneat^ nrie acid, 
tbooa \ij luie Mia 
thnBil oiptrradil. ^'t- 
(rrj(ai<< |*<« luie acid. 
T«nlh4 maUera ptf 
doead by MleUonm gaia 
DO Diio add. 

Juir, 1859. —Ante 

attack iclolll ml, InlM; 

attnn alkaline; ip. ft. 

1036 "0. UaTo nrie Bead 

[9 



^^^^118 BLOOD IN OOUT. ^M 


^H Sam*. 


i 

•* 


OcEUfMlrai. 


tLibiUoCUfe 


PmU>l>u>lUini 


°rn"^'t?"U'"«"«^ 1 












UuuMs 1 










) rMn,lMr 1 








1 wncmtieal 1 












*Eidbl* man 














iban Ihrea 


H^ n. V. 


SO 


rainier. 


Imgubr. 


bwwa. 


O«od anlil 
be bad 
faiDt«n* 

wile. 


N'uniemu, 
Firat anack 
about tbiM 
otfooryaan 
aino^ Is 


^^^B 


4S 


Qiiigtr-l>e«; 


Tnlm I'^T 


None. 


Tntij gwxl, 


NnmartniL 






iMtlwr 


ftwix. «iinr- 




tHDC|lt gout. 


yint aluA 












aboDt Ian 








gin, but noi 






yrmrt mm] 








lotCIUpC' 






wry (»■ 








nM. 






qusotwitlila 

tail £(« 
jnra. Kol 

bi>tai7 
vhi<-h joint 
«aa a0e«ud 
IB 6nt at- 
tack. 


^1 


52 


CoAchman in 


Dnnk 


SiDO 


Oood, mlil 


Vtry MHs- 






f;pntt«mcn'f 


(irtltj tV«elj 


known. 


finlallack 


rau^had 






faoilliM Toi 


■1 an« tin*. 




otgaat. 


nllitwl fbr 






Diu; jon, 


ohicflf wina. 






man; jMia. 

Cum on 

tntb 

ThM 


^^^ 


11 


Port«r; 


B«gaUr. 


Snot. 


VntkjffmS; 






hnnatfy in 






bad Mme 


altMk. 






tiMMnj, 






{MiUoBed 
vounil.Bhi' 








I 






jMrarisc*. 


! 



■1 


^^^^^^^B^^L^^3ZZ1 ^^^^^1 


E 


^^^j 


^^^^^ ILLUSTBA-nm 0A8Ra 117 ^1 


^^^^•«c 


Groflw durtaa AUaetc 


8UU of Bload. ^^1 


^f 




in kbandanen on tbm4. ^^| 


^^k 




Jul IHAl. — AeuM ^^| 


^^^ 




altadi. Abouduot of ^^H 


^^K 




Blic acid in blocd. ^^^| 


^^^ttMk 


FracDtaU*c1c AUtj *flM4 i«inti 


Blood Mnun OonUlni ^^M 


^1 elcarl)! ^c luuiU ; but knaM *nl tM (tiff 


AtnndMiMtf nruxld. ^^| 


HMswdbr 


uul taioful. Canorrtiont in cut 


^^H 


^FttiBk. 


and trgiiDil >i>m« joiiiU. 


^1 


Ha bIub of 


Commnioed to luuid*; tlita faiMa, 


Gol larju and Gno, ^^| 


^Vrum vUl is- aaklci. Ju., te«un» i^KUd. D*' 


MM ; Mnis slk^ia* ; ^^| 


^K daoeui _ pwu afunleof miU tBMn«alf< 


f V- ioa7-sat(ia*p. ^H 

lOOu gn. of wmm i^to ^^H 


^bUBck. Ottr 




^Hfctlgueap- 




O'OU (TMi of uric boA. ^^| 


^^■^ pwfld to 




batf 




^^H 






^^H 


tlM pitwul. 




■ 


An; dc|ira- 




CM iwnut ; Mmn ^^| 


•iaf CMM, 


*Oe«tioniii«M«rniai«joiiiti. Coo- 


■Ikftliof ; tf. XT- 1030 ^^1 


ordilak. 


cmtirai in bud^ ftct, dlaviv !!<-■ 


■t dO* P. ItiOO gniu ^H 


nUindim 


ud oin. OuntyahMcMC^ ((iMnU; 


arMraagwrcotiincMid ^^H 


■ friAa^ 


diKbkrcing son «r iMi a«un7 


O-U (laiii. ^H 


Mek. 


tratoofiMU. 


^H 


^^^ff<rt kiwwu. 


CntnineDHil *l midBicht, m Itc 


Olot Bormtd ; *niim ^^| 


^^t 


ball of l>;rt £i«t to». PntH 100, 


xlValine ; >p. ir. 1034-0 ^^1 


^^^ 


mthcr b&nl, Tcmtfuc fuired. Ap- 


■tTO*?. Abanduiocar ^^1 


^^^^^^H^ 


p«tiM pnttir coed. Altcrwudi dr- 
MiuaMoa M Ain «Ttrt«ltof l4c 
Ho dcpodU of nntci ra ur iwl 


arid >eul br UuvBd n- ^^| 

[icriiDSDt. BMMidUied- ^^H 


^^^^^H 


Inc. attack pMNd off: ^^1 


^1 


(<bo<lj. 


clot Diinnal ; Kroat %i- ^^H 
kalinr; (|>. gr. 1024*0 ^^1 
at SS' P. A Uw em- ^^1 
tal* of oiic uid. AlW ^^H 


^^^^^1 




^^^^H 




l«*T!i>it bMpital, olol ^^H 


^^^^^^M 




■p.Kr. 1037ia(1O'I'. A ^H 


^^^^^B 




1 




few trjBlBla of urio acid. ^^H 







^^^^^118 BLOOD IS GOUT. 


^^M VtBM. 


i 


Oeea^Uaa. 


BaUtooriiAi 


Hnvdllnr 
■■ndUpodlliiu 


Ouwml Mita 
otB-tlib. 


KocfitUek*. 




^^^ 


31 


Uoam 


Diet good ; 


Pktlicir hid 


B«p«*lcd]j 


Ifuaanoh 








ftdator. 


not Intom- 


goat, brsUin- 


kadUU 


ForMTCQ 










p«nb^ 'bal 


•aflitniJfa 


wlio. Qou 


niislliahM 










drink* bwr. 


ftum guiiL 


rorrizoT 


aotbMBftiM 












streajPtuB; 


l^amgooL 














OnTDtOOCBd 
















IntaUof 
















grtkl lo«. 






^^_ 


M 


Cbtl porter. 


tloodlMag; 
■ mniidtT' 
libit ■moant 
tt fatter fa 


fMl«d nitli 
g«at. 


Owd. 


finlaUMk. 

Be-atlMk 

*bci«itlin« 

irttk* nfUr. 

SNOOd 
■HMk. 




^^^ 


K 


Furitn 


Natcood; 


Saat, 


Oood. 


Flnt alluik. ' 








teka* con- 
















tldmUo 
















a BMitUj of 
Wr, kai 
















»om«gta. 










J.C. 


» 


HmM 




OnagnDd' 


Kotprad, 


Mnlh or 






pktuttffoc 


hju drnsk 


fitfacr and 


fram (ro- 


leuthat- 






tao Jteit, 'laaeh pnrWri 


hihrt nb- 


qoenlaniM- 
UtJB tiles- 


tuk. FiiM 








batwB ■ ' aod t|>lilt>. 


JcM lAgont. 


««inmaic«d 








plnnbar. 






dau; E°vi 
kndfalnt«n' 


LDsnattwk 




D. F. .S3 


Brioklftjrtr. 


PrMtjr«pi- 


KlIIKi. 


Oood. 


Fiftbor 










Ur, but 






ristlL Ffn^ 










ilriula ftM- 






ivoTnn 








1; of gin Mul 






tiuMttam- 








Mcr. 






R>«BCCdiB 

Eraat lot. 


iLa 


H 


vDMcr. 


bfnlBr. 


ITol koown. 
Km nvUced 

ID CBM 
bookL 


^iilTen ftem 
Uoncfaiti* 

uiid cin)diT' 
•MU, kad 

from ooMti- 

otpMil. 


ItnmgroBL 
1 



^M ILLl'SrttATlVE CASES. |» ^H 


Omn*. 


«)ravl«qM doriBf ItlMk. BHM or Blood. ^^| 


■i)4M«» 


Sl|ht bot, CfMt tat. boUi uklco. 


Clot ntb«r cBppcdj ^^H 


Mlimi 


kaM% rig^l wriMi mldilU Doger or 


on-sm alkklioe; op. gr. ^^H 


tfuM. 


1^ linti influDtd. INiDfaeeliaQ. 


10380 M 41* P. Aban- ^H 




Kelkint. AppMitoe«oil. FulaaSf. 


d4D0« cf oric irIcI b; ^^^| 




Uuok piUios df twDlbn jvinU. No 


tkreodcxpiirimDiit. Blit- ^^^| 




dtyowto riublttoo knj put of budjr. 


Ur fcriiM, ou i*r(UI ^^^| 


^ 


lU dirt«nlM of jobUL 


reCDTtrj, jicblcd m mo- ^^^| 
denio kBiuuuc of nrio ^^^| 
»eld. Soeood bltadlng, ^^^| 
clot noriDiI. A modorato ^^^| 

blood. ^H 


^^^nttA 


CoomwiiJ kt niglit In ba.tl of 


Scrum avo miirli aria ^^^| 


BUlwwIc 


kft pwt loo, I^M nnUr fiilv of i add bj thtnil rtptri- ^^H 


^^nMr} 


•■Uo. OonddtnbtopIUingnn |irw- . mBol. CioliionoAli m- ^^^| 




■an. Paluilow. ApptUu preltf ; raro, «p, gr. lOSS'S al ^^H 


^^r 


gMti, Ho dcpMU of uiatn^ ' &3' P. ^^1 


f Itmdt 


Eoaw ptfti kfltcttil u barore, aod ! Serum of Uontl e>to ^^^| 


1 MMMdl* 


Hsht giMt twe in addition. 


maoh otid Bcid bjlbmd ^^^| 


1 My. 




ciptriiDcnt. ^^^| 


ht-^u 


Comatooed In Tifhl kDkl«, tlicn 


Cliit nin'ni&! ; nmn ^^H 


1 S^<( 


IsA •nil, Hibl hnM, and right allulinc; ip. gr. iOaiS ^^M 


1 k«p«B*w« 


■niit; ikacklIc«tioaoriA':|<if rt^hl *X 5S* P. AbiindBOM of ^^H 


^EiJi mfc. 


gnu toe. INiIk H. N^pittini arid Mid, Blititr fitU ^^^| 


^^K^ 


BoUotdloDOta. KodqiMitoenuij tloor, no coocalo. Ko ^^H 


^^H 


p«n«fbnl7. Joint ftOoctioo iniM- ari« acid. Siuall qsaa< ^^H 


^^^ 


^MiMcfy (urail vbta cutcbicnm woo ' tllr onljr pmaml. uid ^^H 


^^H 




^^V 


BonSff. 


jcdDt. ^H 


^^EAUmAb 


Tom, uUm; legfra, uiJ vriiU. 


Clol bnflM, not cop- ^^H 


PKh^^m 


PMniwoUon of raliolo. Piltdisoii p(d : wram alkalioo ; ^^H 


r AiiImUjIi7 iMmr*. P«UM. AppMUcI*!. ' ap. gr. lOSQ-J altVP. ^^ 


^ 4it~* 


BUeliaooncwM. A ornktl dopoitt Aboodanoe of una ■cid ^^H 


^^^^^k; 


of «nU «r Nds in loR «j ; ■am* by ario »dd Umtd tx- ^^H 


^^^y 


dUenka ofiMaU. | pdimcnL ^^H 


^^n^ 


OonatMc^blaAkAMudfoot, ' i<tniD oleuiip. gr. ^^H 


BHu>Mp» 


tbMri|blgnollMi,>nvvinUbath 1037. AbanAuiM of ^^| 


r Nn lu ««t 


faMdi,«fMUUf tsdox Gngtr of bit 


■uio add bj thntd «i- ^^^H 


^wlwU. 


KUins (■ pniMiT*, tad dcaquo- 
MaUM of tvlieic PvIm Od, diarp^ 
Appftilejood. )Cod*pa(>Uoir«nM 
■■ a* J fit of bcdj. 


1 


^Mw WM- 




Ctol Donniil ; Mnim ^^^H 


■KhtTlm- 


M«, kIWntda Ml katv. Tiltibj: . >[k*]ino ; ip cr. lOSO-2 ^^H 


f ilkbk«UA 


M tr«»»r«. FnlM lOS, iburi. Ko ' at i^° P. Tbnkd nil ^^g 


"«« 


d«)iMiU if wnim on auf put (^ 
kodr- At Um Um of Mwud 


•priaklfl aitb unc Mi<1. ^^H 
K tonoM Uudiitf alM ^^ 




MiiliU polMml MSmd frea dy* 


pro Duch oris wnd jut ^M 


^^^^^. 


p«t(k araptcM. 


bilon Joint tf «atiM ap- ^^H 


^ 


IpMnd. ^H 



^r 


1 


"L 


HH^BI 


^^^^^^^^^H 


^ 


^^^^^f' 


^^H 


H ISO BLOOD IK GOUT. 


^^^H PKMALBS. 


^m Snot. 


i 


OcMpttkn. 


lUUdotUik 




Ol llHllb- 


It^oTUtM^ 


H 


SI 


Lftiiailnn; 

» midair. 


Bigiilw. 


Fkther bid 
•ome joiat 
tStetion in 
IcMManil 
(tot. Ou 

brothwoUo, 
with whll* 

ilciiotlt* itnil 

cri|'|ikJ 

limlv. 


0«od, tiU 
vithblut 
lu ]r«iu». 


KunaroiM, 
PliatsttMk 
■boo I t«i 
jiuviiiua; 
luwM ««• 
abstad. 

AnolbttBt- 

tMkwa* 

moallii 
i/lcnrudik 


U.J. 


S3 


Sannb 


hiu IJTcd 

ntber hard 

at tinea. 


UotlMrlud 
BgataB4 

okitll: rtoDn. 


■owl. 
rhtbilual. 
Dislafev 

nontitf 
sfWnKrdf 
tfta chM 


nntaltaik. 






lIXrSTBATIVE CASES. 



i:i 



Hri|Md. 



SrwflaD* Marine Allaek. 

CanuDcoccd ku knee*, Ibeo anltlc*. 
ttbovi, writU, led tiuf»t». PdUc 
93, cMb«c lord. No dtpoaiU of 



AbeUngtliBltAiDdM flngtrflnt. 
IhM vtbt Aod ■lionMMa, ebteflx 
■nBU>»lM«orri(hlUsd; leftkoM 

Ud iBMtpu nwqMWntlnn «roUti- 

el«> Kod^otiUoftinU of nds. 



i> ui «r both pMi toM, ftfUf- 

•■rJi ItDiN^ *lu« bkd, joint (lit- 
MM «■* IM «t kll iMtBM. Pitting 

Ml |raBir«. K4 oweMloiia cf 
uMcfaedB. 



suMorniocii. 



Clot firm, buff^id ; w 
mm alkaUno : ip. gr. 
I0-2S0uo&'F. Aeon' 
lideiaMt uiiuunt of uiiii 

■Dtabh 



CIM firm, •lifhllj 
bulttil; Mnim ilknlin* ; 
•p. (r, 1020 a »1 »6' I'. 
Much una nriil b; uria 
add Ihnad experiment. 
Abaodanm of uric ifIij 
fsiiDd in ifnin /nm 
Uitttr, by una *dd 
thnad aiperimatL 

Ctat nipped uf\ buflcJ; 
Mmm klkalluo ; t|i, cr. 
lOW-S M i;0° V. A 
nodtritc unouul (iniall) 

ot nrio Kid. JUiiur 
Kmn nikolino ; ip. gr. 
lOSI-OatOb* P. A few 
errtuli of orie add. 
Snood blMdiss, dol 
bnflod tad onppni ; at- 
ram kikaliott; n. gr. 
10373 at «• F. A 
pr<ctt]r (»ad ■prinUIog of 
tiri« add on Uiitid. 




BLOOD IS GOUT. 



KuK. S«i. 



0, 0. M. 



V. U. M. 



D.N. M. 



J. K. M. 



T. r. M. 



I.e. M. 




Ofi*l» of Mihiek Ihe miniUl d<laili teere tern htMn. 



AnoQut of F»U«tjt. 



its. 



J. 11. 



u. 



u. 



AtUvk ]>T»eiil alwul tht«e 
vmIii. UnrlflubUtl BOuly 
pikliruC. Ma CDiiDrctioa* 
nutiMd. 

AcnU ntUck. Chrotiu 
iHitm of loug (UmdiDg. 
AlwB}* nlieml bjr eolobl' 
cum. CouciniQU in Mn 
■nd joiou. 

A pttient with pml of pMV 
tM uul font. 



TaUert with St^o^ lov 

gout. 



A painter (irriat* anil 
bjuid* affeoUd), gout - far 
ten ymr*. I^ atUek oiw 
;«ar ainM. 

OoDt. Attuk now in 

lEjht hiuid. Svtci'itl do- 
fxialta of Drata or toin in 
bolli can. (EJcdia of Id- 
llamnl parti. 

FntJtDl i]lacn«atil to bav* 
goul bj a pLjuniou. 



0«ut for aaaij jvat. 
Larga jginU tiow chliOy al- 
boUd. Ua* lia4 gnat lc« 
affaction. U(|>r«iu in b«tli 
Mn ; bnt not «lM*btn 
noUetd. 



BultefBlMd. 



Sarmu alkaliiw : ap. ^. 
)U31 at eo-p. 1900 
gniina gaTH of nrio mU 

U'Ufi graiu. 

CIsi llna. nM boffail : 
wmm alkalioe ; up. (r. 
lOST'S at ««- F. 1000 
jnsina gara of nrio add 
O-OSS gnin. 

Sfrnm alkaline : qi. ft. 
10:il'S at 00' V. 1000 

iLraiii* garo at ario aeU 

a-at4gi»o. 

A amiin riaanliljof blood 
Ukea. GsTc abondonoa of 
etjilal* of urie aclJ. 

Sirum atkaliss ; lOOO { 
tniaK Gar* of uria acid 4 
O'DS srain, 



Clot Grm. boBU t aHBi 

alkalms ; ip. p. lltU^I 

TO* P. AbimiliiiMtof I 

add. 



Dol Giro, bafTtd ; 
alknlJDc. Oare u>ncL uriA 
acid hy oris acid tluMd 
eapcriiuonC 

Svnini of blond eonlalaod 
Biuch urie aoid. 



ITBIC ACID IS BLISTER SEBCM. 



123 



8m. 



AMD«nt*rraii«Bt. 



auuorDiMd. 



C IL I SL I A pUlont «r]M hki luffond 
laU7 7«4n fiom aiidDalil«d 
fwrtj •ttielu^ bM on u- 
MwM of rMn>Md(o«* «f tbs 



L r. It 



r. u. 



iMk 4i)Bp|i«ulDg ixpldtj. 

AotU altkck of fiDuc ; Ibe 
tn* aUMk, in grt^\ tu« for 



M. 



Chra^ (ML Or«»i lot 
nAaa »l«<i« aARtal. Ko do- 
p«nla pf unta of bx1> mcu. 

Ftinter, Ooat df gimt 1m, 

«f tira difa' dnntion. Ad- 



Smud klluiliDe ; ip. gr, 
1030-1 at 4a* P. QaT« 
mnob ujia icid b; uiie «cid 
thrvad expcrimcut. 



Scmia gaTc nrio mIJ 
cijiCali on tbrtad. Mot 

S<ruiu ullLalLUii ; £iit« nti 
thriaJ aliimtl:iui.-v of Urio 

IHiitcr nruta gaie arte 
tvci'l I'y Uio tlinwl eiperi- 
meat. 

Clot firm, VulTed : wrniD 
iillikl1ui;>p.er. 1023-0 U 
0.'<* F. Abunduieoarntia 
ociil b; Ibitnd siiicrlneiit. 



.X.T- 



M. I OoBk aith muj mDim~ lUofl ULtJi after ilcatb. 
tiona ID imt%, and amunil Strom b; uri<: acid throd 
jomU. Dtcil tnaa fneliu* of ctptiimcut pn madi nrie 
rcDiKj. . Mid. 



I. 

^M Dt*eoT<rj/ of Urk Acid in Ibf/fuid artificiaUsf ^ffiatd 

^K if lit igtpRoation (jf hiuttrittg agenU. — Some ytan 
^ BBeo nn apportouity occumfl wliiclt oiinbUtl mo to 
■bfiv thai nil en.' luorLiit oQfutdoiM tuko pltioo in 
(■liiMitr. whow 1>lood w ricli in ane utd, thcw like- 
wiw ojatmu it ; ttiia fuct \m» prurcd ns rogonls Itic 
bun tbo poricanlium aiid {tciitoDcuni,* but cuoli 
rU<dgo coold not bo mndc aTaiJablv f(>r any 



MtilW'ChiWHJwl TtMMaiaM, t<>t. lotn. 18S(. 



124 



BLOOD IS GOUT. 



pnietical piirpav. It frequently happen!) that, for 
for Hio sake of tliag^iosis, it is deHinible Ut n.'wi'rtai; 
tho cotniitiun of tiie blond, as to the presence or 
abseiici> of urio aci<l, in ciibps wliere from the state of 
the patient or other caused, Tencwction cannot well 
be omplyycd. and it occurrcl to mo that probably tho 
fluid arlificiaUij i-lTui^-d by the application of a blister 
would oiitdin thi; neid, if tho circulating fluid were 
impregnated with it ; experience proved the truth of 
this conjocture. The following are some of the results 
obtained by tho oeq of the thread experiment, a test 
whicli may bo employed for the discovery of uric acid 
in blister as well as in bloi>d serum. 



4 



Feb, D, 
lES). 



J. W. 
Muicb 5. 






J. H. 
Hucliap. 



C.8. i 
Jon* SO. ' 



M. J. 
Hot. S. 



i Scram of \f\otA ; 
ip.ir. 10S9-3 M 41- 
falir. AbaQdnDM of 
urie uld on tbrauJ. 
' Svruin of klanil : 

ip, IT. io»(j'( It sr 

1 Palir. AbnudnDin of 

\ uiio acid. 

r Bcram of blood : 
\ip. gr. lO-Jt at II- 
SKtbl. Abulidnnow uf 
\jat\e acid. 

[ B«rnin of blood : 

lip. KT, 102&-a lit iV 
I Fibt. Abonduioa of 
[nriaodd. 

Ho bbiod tOw. 

Boram nf blood ; 
I ip. (T. lOSfl 8 at 62* 

Habr. Ofttdliof urio 
I acid not Tei7 nam>- 

Tcnt. 



E. W. 

Feb, 11. 



J. W. 
UanbS. 

J. W. 

Msrcb 2S. 

Attack 

jMiflilag 
eft 

J. n. 

AprU 1. 

c. s. 

Jono 30. 



H.J. 
Koi. 11. 



SPfrniD of Mit(«r. 
, Abiinduiue of Dric 
(•Old. 



I SfnusafUMK 
\ Abonduw* «r aA 
(acid. 

I Bnwn of bUittr : 
Imp-. 1013 -Sat i«* 
/ hhr. Cmlakof odd 
Hid. 

( Sernm of UUer : 
)«p. gr. lOSl-Salsr 

(Pahr. Abundanecaf 
urIo add. 

r Somm of blitltr. 
i. XamcnoisiTVlalatf 

1, un<i aoid. 

Somro of HUtfr ; 
*[>. gi. WH at I'.y 
Kabr. Crjitaliof arie 
arid, nrrnJ in Dum- 
ber. 




UniC Acm IK BU8T£B SERUM. 



lis 



1151. 



I StntB at bleed ; 

tp. ir. 1024-8 ■( SO* a P. 

F*kr. AbnuduM of Jan. 13. 
I ari« MiiL 



k Smm of bliiler; 
! uioJcrata tuaaant i^ 
I arid xriil. 



It nppcAT9 from the nbovo olscrrations that tho 
_8tud i-ffuiw'd by tho odinn of ii lilistcring agpnt applii-cl 
I tho %kln, irttl giro c%'idvnco of tliv presence of urio 
. wbt-ii ttiL- blood fnjm tht- same patient pshibiu 
i plwodmpiicn. In thu pcrfurmancv of the thread 
espnritDcnt, eimilar prccuotiong must be adopted as for 
libiml-MTnini ; bat. In addition, tho applicutioii of tbo 
ti) an tnfluincd Kurfaoo should bu nvoidod, as 
nisU'iux^ of in Hum mat ion, ut least of a gouty 
l'dianict«r, hw the power of destroying the uric add, 
and pn-Tcnting its appcanLiico In tlio sltuhi;* tlufi 
bet u proved by tlio subjoiuud obson-ntions. 



OL P. ) Swum «f blood. 

iiM. S> / Ab«ad*om of wig 

1W4. \ »ai. 

r. p. ) Sarun U UmJ. 
Jul li, } Abuu<]MiM ct nrlo 

141. \tid. 

tn C P. 1 Sena o( blosd. 

Bk tl. lAbnuUno* a( nric 

Un. Jaeid. 



a F. 



F. r. 



acL F. 

Dm. ». 



f S«rnnifnrm bliat«r«Ii 
t ihg dcifaum uf tbo hand 
J rliflilDHl wiib gout. 
[ Xo tnra of nrie add. 

I Btrom fnm bliiUr 

(kne*. Ko tIMe of 
uri<> a^d. 

SStnin fiom blister 
AQ inlUiiial (loal;) 
iknte. No InM of 
( nile ■ibL 



Dnrin;* tJio cryHtaUsatioii uF uric add in arti6ciaUy 
Ihwd fluidji, & form soincwiiat <liffcring from that 
wfaifih oocun in bl<HMl->orum is apt to bo aKumcd, as 



■ TW dI()M InfawiMtfdH t««dw(l Igr • bGitfr do« doI *|t**r *" 



1» 



BLOOn IN COLT. 




the cr>'vta]8 liavc tv gre.tt«r tendency to ngglutiiintc 
and fonn irrcgultr mussoH. 

Should further tnquirioa coiifimi the conctuf^on to 
whicli the ttbove limiu-il number of observations point, 
that during the- oxistoiico of gouty inflanimatioii thcrA4 
is a gruduul det^truclion of the uric acid in the blood, 
and other indepnulcnt rese ardies which I have inado 
appear to fnvo«r this idea, it will throw uo small light 
on the pathology of gout, and rxplniii the reason of 
tho improvement In tlic geuorul heultb which fro- 
qucntty follows a sc%'crc and pruloiij^ fit of the 
malady. 

C/va iit fhe Blood in ca*es of gout. — Tn tho Jtcdieo- 
Chirurgical Transactions for 1848, 1 pave tbo result of 
some invostigationa made od the blnod in gout ia 
reference to its conttiining urea, and came to the 
ooncloiUOQ that this prindjilc b sometimos present in 
excess, althouj^h nut in quantities at nil equal to what 
is found in albuininuria ; at the ^ainc timo it was 
suggested Unit the urea being retained io gnaU 
amouuts might explain ouc of the e^jniptonu of goufy 
infiammation, namely, the frequent prescuoo of digbt 
ladcraa ; nncc this period I have made further otn:; 
seriiitioiis, all confirming my originiLl stati-ment. Dr. 
William Budd, in a paper puhliMhcd in the same 
Transactions in 1855, confirmed my observatiomv 
though bo ascribod the prcsenc*? of urea to the deoom- ; 
position "i uric acid, nnd not to any defect in tho 
excreting power of tho kidneys ; hut such an explana* 
tion is totally iusufficicat to account for tho accuma- 



F 



CBEA ASD OXAUC ACID IN THK BLOOD IS OOUT. ICT 

lation, provided ttio fonction of the nmal oi^^na 
icmaiDS ititnct. Dr. Badd gives details of Wo ca»(.'8, 
and mentions that he haji detected urea citlior in tbo 
blood or blister serum of sevcu other pi^rsons .■flifliTing 
fimn acate gout, in none of which was albumen found 
the urino, nor was there any other indication of 
presencti of ronnl diseiuw. It will be seen, how- 
ever, fortJtcr OD, that a trace of albumen is frequently 
present in thu urine duriDj; tlie height of n gout)' 
pnnMeysm, though not discoverable ut any other 
period. 

Wo may conclude from thtise ubserv-ation^ tliut 
mt* ia ofU'ii contained In abiinmud quantities in the 
blood in gout; wbotlier it i.s ho in the very early 
ftttiKlu) has yet tu be determined, but of this wo are 
errtain, Unit st audi tiinci) we always liud uric a«id in 
netm. 

Occurn^Cf of Oxalic Aeiit in ffotitif blood. — Soiiiu 
yum iiiiu:!' * I ilctocted oxalic acid in the blood of u 
pntiiiit tubtiuring under albuminuria: whether or not 
be bud raffrnd from gout I am unable to Any. Tbu 
■ad WW •Tjiarateil from the watery solution of tho 

fMentm, mostly in the form of octohednd crj'rtabi of 
itzalato of lime, but mixed witli smoU oval bodies 
Mnumbut rescmhliii); the dumb-bell rarieties of thL* 
wit (Vii^o C, (i)*. 3, a, c). I tuvo «l»o examined tho 
■iod (ur this add in many cue* of gout, and baro 
Ercqntaitly detected it; my impression is that it chieBy 
*NXar> during tho tntianunatory &1agc of tho disease, 
• Ilwllw-Chinnlid TnaBMOcM, vol siilL lIlO. 



BU)OD IN OOUT. 

and is probnbly derived from the oxidation of the nrio 
Etdd. 

The whole subject, however, is beset with diffiuuIUea, 
iind, uiitii innii)- other observntionR have been made, 
I difluld not wi.ih to venture any poNtire statement, 
cxcqit M to the fuct of the frequent oecurrcoco of 
vxulio ncid iii the hlmxl of gouty subjects. 

Tnrcet of Uric Add and Vtva in hinUhif klooil. — In 
1848, in the postscript to my communication in the 
Uodico-Chirtugieal Traiuaotions already referred to, I 
stated that I hod not only discovered ui-io acid in the 
hlood of gouty piitteiit«, but hnd found it also in 
hoalthy human bloud. This btotomcnt haring been 
somewhat misuodcrstuud, it may bo well to explain 
my views more fully. 

It has been asserted that, as uric acid bait boon 
found in the blood in health as well as in gout, 
the iiniiortance of thu latter fiict becomes greatly 
climiuinhcd, but, on due conaderation, iiiis deduction 
will bo found erroneous. In health, mere traccfl exiift; 
quantities which require the cmploj-mcnt of a largo 
amount of Uuod, aad the most careful chemical mani- 
pulation, to enable us to detect even its presence, and 
whioh cannot be shown by the thread experiment. 
liDio same objection might, with equal trutli, be wgod 
ogfiinst the value of tlio presence of urea in oasoa of 
albuminuria, because I luire also detected this principle 
in healthy blood ; tlio diflerenoe in the amount, how- 
ever, in the two cases, is verj- great. Traces of all 
the prioGiplcs contained in the uriac are probably 




PEBSriBATlOK IS CODT. 



1» 



lit in the blood, although it w only from dcfpctive 
thnt thoy ocoutnulatc in eufficicnt quantidcs 
' h beeomo tlio source of dwcasp. 

CBrbonic odd is a oaturnl coRstituout of ihc- atmo- 
^berCr >nd aim of tbe blood, but it is only w1il>d its 
pioportion is increaiied beyond a certain limit, that 
it prOToe injuriotu^ to Um functions of the animal 
OBonomy. 

Sterttion /rom fhe akin in ffouf. — There are innny 

ioatanoea on record in whidi a whitish powdor has 

bMD noticed as oocurring on the bIou of gouty patients, 

topcfiiillj' after proAue pcr^iration, and it baa been 

freqwntly supposed to consist of some combination 

of ttric acid, but in most case« a:<(<timod nitbcT than 

pnred to bo urat« of soda. Swcdinur stated that ho 

bad Men a patient, labonrtng under a severe gouty 

paroxyADt of sevornl months' duration, with (he entire 

mi&oe of the body covered ovcry momin« vnth a 

vUte powder, as though he bad been ducted with 

Aom. WoUT thonght ho had dct««t«d uric acid in the 

peitpitstion fotm a patient suffcnnf^ from calculus, 

■ad the Muno was stated to oceur by Dr. Muyer, of 

Madras, in tbe cnsc of n gentleman who also suffered 

tnMD (tone in tho bladder, and sapprcssion of urinei. 

In tbe latbT inatanoo, I think the statement is open 

to doobi, aa tho add wax obtained from the vhirt worn 

by tho pattest, who had recently had n blbitcr ai>]>lied 

I tiie back, and we hare shown that blister serum is 

Fat tinua rkb in this principle. 

Dr. Oolding Uird, in bis work on arinary deponts. 



Itt 



BLOOD IX GOUT. 



also mentions taving noticed tlie appearance of frost- 
ing, from ijiicroacopio crystals of urnto of soda, on p»rls 
in wliioh the esudattoa of an eczcmatous crupdou had 
driod, tbo patient being bed-ridden from rheunuitio 
gout, but it is not stated that these crystals were ohe- 
micaUy csamincd. Tho most positive obserrations oa 
this subject wcro mado by Dr. Charles Petit, who 
affirmed that he had taken tho cuticallir socretioD 
from tho skin of gi'uty paliciit*, occurring at the t«nm- 
Dation of an attack, iind hml it cliL-mically vxomioeil 
by M. Uonnr. Tho first portion was froui tho hand 
of a putii-nt fifty-six years of ago, who hod soffered 
from Uio diseuso fioni the age of twenty-four; it 
contained about four-fifths of its weight of albumen, 
some lactic and pho»'plK)rio acids, chloride of sodiom, 
and phosphate of lime, together with sensible traces of 
urate of soda. In another instance, the matter was 
tukcii from tho surface of the ohest ; in a third, from 
the back of the foot; in tlicee specimens, also, )[. 
Henry demonstrated the existence of urate of itoda. 
Some objection, perhaps, might be urged against IheH! 
results, especially when tho matter was derived fix^m 
the hands or feet ; for if the patients were the subjoots 
of depo«t« of urate of soda, a portion might paisibly 
hare been detached with the cuticle, as they fre- 
quently approach the surface, and even beo(Hno 
exposed. 

Some years inncc T adopted the following method to 
ascertain if unc acid is thromi out in the perspiratioD 
of gouty patients : A man was selected suffering from 



rERSPIK-lTIOS ra OOUT. 



lUl 



^ 



II screre attack of gout ; he Lad been subject to tho 

ditoaac for a long time, and had many tophi, or con- 

cratioos of urate of aoda ; bis blood also gave «\'idcn<!0 

of oontatiuiig a largo amount of thiit princdpl<>. Scverit] 

fbid* of white bibulouti paper were steeped iu a weak 

eolation of jNitusli, and applied fur about thirty houis 

to tho abdomoD, protected by oil-^ilk. The papcn; 

were nmderod acid aud found to bo strongly improg- 

Bated mth tho penpimtion and to contain mueb 

organic matter ; they were treated witli rectilied eqilrit, 

and aftcr«nnla with hot water, and tho watery solu- 

titm, when evaporated, carefully examined for tirie 

■dd. No traoo of thitt body could bo discerned by the 

murexido te«t) nor any cryitUIs separated by the addi- 

tioD of acetic add. 

More recently I bare made two otber ohscrvaUons 

with referenoo to this mihject : A man was sclootcd, 

avflering ecroroly from gout, with cxteDSiTO dopo«t« 

of ttrato of soda in different parts, tho great toe being 

gieatly affected, as »hown in Plato 1, lig. !i. Tho 

nuiclo from this part being very thick, was detached, 

■nd after digestion in alcohol, treated with warm 

Water ; the watery eulution was then evaporated, and 

■actio aeid added. After remaining for some houi9, 

■ nty few mtcnMOopic cr}-i!tals of uric ucid were 

iHworercd. In this experiment »uinc error may have 

arisen from tlto veiy eloso proximity of the depcnts of 

Aslky matter to the surface, a fact well indicated in 

tho drawing. 

Is tho second case the band, fore-arm, and ann of 

a 1 



m 



BLOOD IN corr. 



a gouty patient were placed in a voiy long aitct vndo 
glass jar, tlie vspour Lcin^ prevented from esi'jiping 
by means of caoutchouc slicotiug ftttadod to the 
arm ; a considoriible quantity of the perspiration, 
amounting to Beveral drachms, vras thus collected 
and subjected to analj'si!!. Ho uric acid could ho 
dlscu^-crod either in the form of cryatiU» or by tlio 
muroxido test ; but in lieu of this body a. considerable 
quantity of aralate of lime was found, a portion of 
which hud crj-stallised on a fibro iii the evaporated 
liquid, and ciJiibited tlie appearance 8ecn in Plate 5, 
fig. 6, &om a drawing made nt tlic time. It will be 
observed tliat the crj-stals ore of the octahedral variety 
(Plat<' G, fig. 3 «), and some are aggregated in the 
fiirni of rutiiincntary calcidi. The patient from whom 
Uie perspiration was taken was suffering from an acut« 
attack of the disease, although the arm itself was not 
implieat'd ; a large amount of uric acid was present 
in his blood. 

After an investigation of the rariouB conflicting 
statemcntfl, with regard to the seciftion of uric add 
by the skin, I feel desirous to pause, and await tlic 
result of more numerous obser^'ations, before giving 
a poativc opinion. Considering tho nature of the 
excretion from tho iJdu, it would bardly isovm pro- 
bable that a body possessiug llie properties of uric 
add should be thromi out with it, either in itd free 
stotc, or in the form of a tudt ; but, on Uie other 
hand, I could ea;^y imagine that the fluid from 
ccxcma, or, iii fiict, from any other cutaneous crup- 




PERSPIRATION IN GOUT. 



133 



tion, wlicii occurring in patients whose blood is rich 
in uric add, would contain tliis principle, because 
sacli secrctiona arc alkaline, and boar a close re- 
setnUancc to the Bcnim effused by the application of 
a Ulster. 




IN 



UBINB IN OOtrP. 



CHAPTER V. 



VUn Rt OOCT : — CBABICTBIU OT HULTRT CKtMS — Tl-BLt tSiriBR- 

nra m odhpmitioii ur dnihi mc tuk mii.t KUiiiiiitiair 

or in tHF»IBtKI COmTlICKUTi— DK* iOID— Till IIIIIII* Ul 

vnicn IT EiKTB :s ts» cnts« — mmiiox ii»rw«u thb 

AOtMTT or ritlSH AX1> TBK DKIO lOID OOrtAIURD 11 IT — CO*' 

BTTion Of THi mum m i^tiTiE aout— no ixmMiTi ixchrtms 

or DUO lOlD U lUKT 0.901 — XLIHISinOR Of tHI VHlJt BPt 
Lim.1 ISnCCKPtD — (TKinL IK OUBomP OODT — ^ErICIEIT XICU- 

TIOJI 07 DHIC XOID— ho HillKID DBHOtSlICI IS THE «IC«Kt«0 
ITKJU — PMlliCltXt rRNRaOK OF SMALL AKOCm OP ALDCrilBX — 

num or ooctt iKnirmuiLs m tnu hitkeval)! iif tuk rtr* — 
nouDLR xxmiiTtoN or rut tamvtcFt RETOiticn or hoot— 
)ii<nu)aoon« oniKACTiiw of tri uniii ix siFFiBm rcuis or 
ooni. 

JlKFoni! attempting to explain what has hitherto 
bpon iiscortiiiiied concpraing the alterations of the 
urine fh gdut, or what, from our own observations 
and experiments, we have recently arrirod at, it will 
bo desirable briefly to bring under notice some of the 
more important properties of this secretion in the 
human suhjoot. 

The urine when first passed is of a bright amber 
oolour, transparent, with a peculiar characteristic 
odour iind distinct acid reaction, but when allowed to 
stand for a short time, a fine flocculent cloud is depo- 
utcd, consisting of mucus with a few epithelium scales. 

The urino is subject to nmnorous changes, both in 
appearance and compodtion, and hence the ancients, 
who only studied its phj-sical appearances, gave 



i 




I 



difl(>rent names to Uio urinu secreted at dilTcrcnt 
petiods of the dny, as urtH/i polus, to ttiiit sccrt-tctd 
ibortly nftcr iiigc-iting n onsidcraLIc quantit}' of tlriiik; 
■rwa eibi, to thu iiriiu! jiasHcd during the digctitniti of 
ftaolid meal; and un'ita sanguinis, to the anne sccri'tod 
firom tho l>lood, and uniniluLiiccd by food ; tlie uriim 
|»tus Iios a polo coli>ur, und luw epccifio gravity, tbc 
ttrina cibi u botb hcuvicr mid darker, wborcas tho 
anna nnguinis Is iatcnnnlLittu iu cLaniot«r. 

Tho qtiuiitity of urine jnis8t'd iu tbu Iwcnly-fbur 
boun is likcwiso subJL-ct to conaidtTublo vuriution^ 
depending on many circumstitoovs, as iu dividual 
pci.'uliariti<.-», the amount of fluid in^tcd, and 
tho condition of Ihu atmospbcro; it may bo re> 
glided BM II rule, tbnt bctwcuu the skin aud Idd* 
ncys A ricarious iKtion DxitttA, and tliat wlieu the 
aecrvtiftn of tbc skin k largo thu unno is i>canty, and 
vieo yvnt, ; Htill a prvtty clo«c appnuciniatigu to tho 
avenge may bo arrived at. Dr. Prout considered 
that the daily quantity in summer is 30 fluid i>unco$, 
in winteT 40 fluid ounces, giWng as a mcoD 35 
onnecs ; he oIho thought that the specific gra^-ity in 
health rariee from lOlS to 102-!i, the average being 
1020. H. Becqncrcl gives as the averse specific 
grant}* of the urinv of both sexes 1017, mid the 
aTorago qtiantity in Uio tweiit>'-four hours about 46 
fluid ouooMS or twenty thousand grains. 

Dr. Forkcfi, in his recent raluahio vork on the 
Mnpontion >if the urine, gives as tbo mean rjtinntity 
i^'four hours, 52^ fluid ouuocs. Thid number 



' 



UEISE IN GODT. 



was deduced twm ntuaerous observations made by 
diffeixnt individuals iu this countr)* and abroad ;'tbc 
Tiu'iutiotiii fi'uiu Uie incoii {u uny one day may be 
coDudcTftblv, ulUiough where tlic bctdtli is porGeot 
they seldom extend beyond that timo. 

Id composition, urine may be iTprosonti-d as water 
holding ill Hulutiun ecrtaiu organic substances and 
ealU- Bomo of the \xst analyses of the urine in 
hialtli lire those mudo by M. Bccquurel ou several 
inJividuaU of both iMxc^i uud c^pi.'ciHlly vtduable, 
inosmuoh ns they inuludo, uot only the eomposition 
of thiM fluid in the 1000 parti^, but also the total 
tflimination during the tn'ciily-four liours. 

The following tabic ^bows tbu results arrived at, 
reduced to Englidi grains and finiJ ounces :* 







Hau: 


PlHALC 


Mux. 




UriDtoI 

Hheium, 


InlOM 


Uriuot 
M hnurs. 


In imw 


UrinseT 
II hsun. 


In ion 


Qnantitr of j 


1019 


1000 


4li i. m. 

lOlS 


1000 


1017 


lODO 


Wnler , . . 

Solid* . . . 


isBioa 

803 '9 


908-S 
SI -2 


20W2-S 
628-0 


07S-1 
1^0 


19796-2 

Gss-e 


971-9 
28-1 


Uric add . 

Orgnnio *tid 
Tulililc ,"«■ 
lincUntlAiB 




2707 

rs 

150 'G 

IBM 


13-9 
0-* 
7-7 

0-3 


S104 

8-S 

130-0 

tio-o 


10* 
0-4 

e-1 

S-0 


2S50 

8-1 
IW'S 

ids-0 


12-1 
0-1 
ft 

se 



' SJmdiotiqiM iIm UrioM, fu 11. BeoquMeL 



CIIAttACTEES OP HtALTUY ITRINE. 



1S7 



■ 



I 



TTtulcr Uic head of ^ctl salli, dilorid^ii, phosphates 
nilphatGe of potikih, twdu, Hino, unci magnesia 
mre included; and under organic and tolatile saline 
tmmHert, crcatioo and creatinine, hi[i]>unc iicid, co- 
looriag, and many at prosent imdetincd oxtnicti^-o 
matterH are grouped, with traces of nmiiiiinia mits. 

A> we shall dwell porticularl)- upon the ult«.i-»tion8 
vi osrtaiD of thcao oomponCDta, and especially of tho 
orio acid and area, vhcn considcnng tlio urino of 
goaty fiabjecU, it will be di^sirabtc to notioe them a 
tittle more in' detail, and aUo allude to some of tho 
man important characters of tho renal secretion. 

Ttic apf^ijle ffntUff or density of tho urino i-nries 
with the amount of solid mattci-t; contaiiii>d in it, but 
it must be remembered tliat we cannot, witli any 
approach to accuracy, determine tbeir ouantity by 
tho i^ecjfio gravit)* alone, as tho aame weight of 
dtflnvnt RubHtoDcea diwolred in water givo^ to that 
Said r«ry different degrees of dctL^ity. Wbrn tho 
vholft of tlie urine i» collected, the diet <>f tlio jMttient 
remaining tho same, then the density will giro a 
tomewbat close approximation to tbo quantity of 
Kilid elimination tn the twcDt)--four houra. In tlio 
■aalypea wo shall have to detail, the den»t)' is frc- 
qMOtly stated, and tolonibly accurate deductions aa 
lo the amount of solids may often tbu4 bo drawn. 

The next property to consider is tho aeitfi/;/ of the 
urine. It must bo remembered that in heiUtli tho 
•MTGtioa is acid, probably always so in perfect healtli. 
■Ithuo^ at different periods of tho day it is eubjcci 



188 



miNE IN GOUT. 



to considerable variations, depending on the condition 
of the stomach with regard to the digestive process. 
It haa beou clearly sUown by Dr. II. Benoe Jqrm 
that immediately before each meal the urine exhibit* 
the highest degree of additj-, and that whicli is 
parsed two, three, or more hours after fond always 
shows a much lower degree ; the decreiific being 
greatest three hours after breakfast, and five or mx 
hours after dinner, when it reaches its lowest point. 
Tlie acidity of the urine again increases until imme- 
diately before a meal, when it attains the highcct 
limit ; animal food causes a greater and more per- 
manent decrease of acidity- than vegetable. There is 
one fact that must be carefully borne in mind, namely, 
that the presence of uric acid has no influence npoa 
the acidity of the urine, for this reaction probably 
depends, not on the existence of any free acid in the 
Huid, but upon tlio presence of Uio acid phosphate of 
soda, although in some cases of disease it is not 
unlikely that the occurrence of free acids may add to 
tho acidity. 

The eohiir of the urine in health is in the inverse 
ratio to the quantity passed. When the urine fiwn 
any cause is scanty, the colour becomes deeper, and, 
on the contrnpt', when a large quantity' is piLeed, 
it is much paler. In disease, the colouring matter b 
subject to Gonndcrablv variation, not only in quan- 
tity, but in ciiinpositioii alw. 

Tho daily avcrngc of un-a, according to tho above 
taUe, is 35S groin?, or 270'7 graiiu, iu the male, and 




J 



CHABACTEES OP HJL\I.TUY mi.VE. 



100 



240*4 in tbo fcmnlo. Lohmann found, from ex< 

pcmnoDtn on his crura person, that n-hcn living on a 

mixM diet ho piLSitcd 500 gruiiis ; on an animal diet, 

ftS much lu 8Id graind; on it vogrtablc diet, 346 

grsins ; and lastly, on non-nitrngcnisrd food, 237 

pains ; but the averagipB of this physiologist are very ■ 

Jat^; not only f«r ur&i, but likywiso for uric acid. 

In ihiit oftuntr)- the avcmge may bo taken at about 

600 gmiiLS when an individual in in perfi-ct health, 

Kod is liriug well: wo shall find many of the 

ualyrcs for un>a, detailed in the present chapter, 

&il to exhibit thin lunount ; but as tlicy were on tbo 

nrino of patients who were kept on a moderat^'ly 

fpaiv dirt, on noconnt of thu affection under which 

thcjr were lakmrinp, wo canaot conclude from Ibis 

But that the excreting power of tbo Wdncys was 

deficient. Br. Parkos gives 5I3'4 grains as the 

atrenigo daily elimination of urea by adult males, 

dedneed from a rer^' large number of analyses by 

I ^twpl"*' and foreign phj-siologist^ tbo extremes being 

^1 3W and 688 graioA. 

^H Vnst of the anah'sos upon which we shall bavo 

^V McasBoa to comnwot having opedal rcfiTenoo to 

^H wrie aeid, tho ctmndcratioa of this prindplc booorocs 

^B mvested with considerable internt and importance. 

^^ "We haTo SOW! from Bpoquerel's table, that eight 

gnuns is tho aTorsgc quantity poascd by the healthy 

human tubjeot, and many other itiwstigatots have 

arrived at a similar remit ; but uric acid is a body 

I wbidi in it« finw state is scarcely soluble in cold 



KO 



UBISE IS COOT. 



water, requiring from twelve to fifteen tliousand parts 
for fiolution; it ia also very sparingly eolullo in boiling 
water. How, tlicn, docs it exist in tlio oriue, seeing 
that the quantity of water passed dally is not equal 
to the task of holding this eight grains in solution P 
' Many and varied (pinions have been adraneed by 
different cliemists to account for thi» fact. DcrscUus 
considered that it is rendered suluhle by tho coloorLng 
matters of tho flocrction ; Dr. Prout, that there exists 
an acid urate of ammonia in tho urine, which imparts 
to it tho acidity. It appears from moa- neecnt obscr- 
vadnns, that uric acid in present in tho mine chiefly 
in the form of urate of soda, which is capable of 
exiftting witliout decomposition, in a golutiou of the 
aoid pha>i[>hfttc of soda ; hence it is ei'ident that there 
ia no necessary relation lietween tho amount of acidity 
and the quantity of uric acid present in the urine. 
The experiments of Dr. Denco Jones uppeiur to indi- 
cate that at the time tho urine is very add, thcro is 
but little uric acid presL-nt, and when uric acid exists 
in largo quantities, tho urine is somutimea neutral in 
reaction. It is likewise very important to bear in 
mind, that the presence of a urato doposit is no 
proof of an excess of uric acid in the urine^ for urate 
of soda ia held in solution in smaller or larger quan- 
titii^ iu proportion to tho acidity of the urine ; this 
is readily shown by adding a drop or two of an acid, 
such as occtio aoid, to a dense and almost neutral 
urine ; if much uric add bo present, a copious cloudy 
deposit of urate of soda 'nill immediately tako place, 



CONDITION OK UBIC ACID IN THE VmUK. HI 



W 



whidi is slowly conrcrted into fi^i<tjilliscd uric acid 

dcr tlio influroco nf ttic frci? acid wbicB has been 

The gaino result oHvu cusacs, whoa a few 

dropi of uitrifi acid nrc nddcd in the cold to i^iicli 

mine, and the pivcipitato, wLicli at first appears 

white aiii] daky, has often been mistaken fur albumen. 

Not uiifrt'qii (Tilly, if tlic iirinc bo very acid, either 

from containing free acid at tfac time of its emission, 

or from itfl s|)ecdy fonnatioD, one acid becomes dc< 

{Kwtcd in the funn of rhombs, moro or less coloured 

and vaning in shape. (Plate 6, fig. 1.) TJriae 

which has given rise to such crj'Htalline deponts, 

oontiuna Korocly n trace of uric lurid in solution; it Is 

IB Gurt, in the tamo condition iv> when a foreign acid 

hot been nd<lc<t. 

Hu dinieal observatiun thrown any h'ght upon the 
diutges whidi occur in the urine in gout ? In most 
of the workj devoted to the oonHderatii>n of the 
diantso, little thut i« )uttisfuct<:)ry con be fuuiid ; some 
authors pose over the subject ultogelhiT, others con- 
tent thcmaolvca with giving a very m(^agn> account 
of the conditirjn of thia important fluid, and erropt 
and dtscrepaQci«« are oomitantJy met witli. Perhaps 
the most prevalent idea is, tlint urio acid in thrown 
oat in excew, lutd in support of such Tiew it is 
ateU<l that eopimu deposits of urio acid and urates 
•rv ao frequently aocn in the urine of gouty pattints 
that the appoamnce of l«ick-dust sedimoots has 
bean rcgarditl m ohnost characteristic of tlie nrino 
in thii disorder ; added to which, there is a pre- 



m 



UBINE IN GOUT. 



Talent irnprcK^ion that gouty pati«nt» nro liaUo to 
attacks of iii-[)liritic gravel, wliich would, at first night, 
apptur Ut «tn-ngllu'u the abuvo gvtu'rally rcwivtMl 
opinioiu 

This subject IS trcntod more nbly and fully by the 
late Sir C. Scudnmort! than uny uthor writer, imd the 
Eubstuncc of his n-murks may be ^'cii iu the following 
quotations : " Tlic urino is of n dovpor colour thsn 
nutuml, is scented tteuntily with rclution t(> the- quan- 
tity of the piiti(.'iit'.-( drink, and on cooling, ilcpoats 
a pink or brick-dust sudimont, witli much mucus. 
The specific gravity is increoficd b<>y(md thi' healthy 
standard. During tht< most urgcot symptoms of the 
paroxysm it is usually passed with cousidorablo irrita* 
tion, both as to frequency and scnao of heat The 
pink or lateritious sudimont appcant moro or less in 
ereiy portion of the urino during Uio inflammatory 
aymptonu." 

This description of the conditioo of tho urine is 
intended to apply to genuine acute gnut, occurring in 
patients who have not previously suffered from the 
discoeo in it^; more ehruiiic forms ; fur it is remarked 
in oUkt parts of Uio same work, that " it is very 
commonly found, upou iiiquin,-, that the patient haa 
aotiood a ver}* di'ticicnt secnrtion of urino a short 
time before Uto occurreuco of tlio paruxjism, and 
conaequcntly it has been of a deeper colour than 
natural. It nl.sii now and then u^^rtuinly occurs, that 
fop a day or two before the fit, tho urine is passed 
copiously and of a pole colour, but this seldom 



\ 



rm'EICAL CH-\BACTEES OF tfRIKE IS GOUT. IM 



I 



liappeiis except in piTMiiD of a ncrroua tcnijipriuiieut, 

and wlicwo constitutions hiiro keen much vciikoiicd 

by (TtJUt." Aguin, tlw samo author observ«K, " A 

(k-piNsitirHi of piuk «r brick-dust Hodiiuciit oq tho 

oouling o( tho urine, is of ouclt ordinary occum-nco 

wheo any active symptoms of gout m-e present, tJiAt 

its oonnoxiun becomco forcibly impressed on tho mind 

of tho patirnt, und ho gives it the name of gouty 

oriao." Thc«o stjitomcntH agreo in tho main with 

thuM of othor writers who have noticed tho condition. 

of this wcTctioR ; but, un tho other hand, it ia ob- 

■erroil by Sir C. Scudamorc, that, "in ao^-cral cxiunplc« 

of chalk ijtoneis both in tho hands and foet, I havo 

lou&d by r(-pcat<>d i'X]K-rim(.-utd u ilefliuoncy, iind oomtv 

tunn) total abt«ncv of uric add in tho urine. I 

mart add, however, that even in patient« of this 

daw, duriof; the p&rox)'£ta, this principle has existed 

iti tho urine in consitlcrablo (juoutity, and in tame 

OMca Ut the extent of a copious depotdt of piuk 

•edinu-nt" 

Tlir above statement ns to the physical appearances 
at tbu uriuo in different forms of gout, are^ I believe, 
cawntially correct, and my own ubservationA arc not 
■BtagDOifitic to them, altltough I consider tho dcduc- 
tiuns which have been usually drawn ikaa thom 
very vrroni'ous. 
H. Berthollct found that a few dayn prior to tho 
of a gon^ paroxysm, tho uriuo lust ita natural 
mUUff, but regainifd it before tlie temiinatioa of the 
IL Foaieroy, in reference to these obeert-atioos 



141 



ITBISK ra OOUT. 



of Herthfillft, oxpivssrd a dcsue that the urine of 
gouty patii'nt-s should bo examined, to sec whether 
the uric oriil was liltowisp deficient duriog an attack 
of the diflorder, Tu many wnrks it has been asserted 
that M. Ikrthollet fimnd the uric acid deficient or 
alisent ut Hich tiinea; a statement which appears to 
hnvo anACn from an idea that the acidity of &e 
urine depended on the presence of the uric acid 
in it 

I shall divide my clinical examinations of the oiTDe 
in gouty patient^ made during the last fourteen years, 
into three classes : — 

The Qnt iocludc-s analyses nf the urine in cases of 
■cute gout ; tlie second, cxaminutioius iu putioala 
BuBbriog from the chronic form of the disease, and 
in the third class will be found the rwults nhtaiacd 
in gouty individuals at a time when there was on 
abiscuco of any symptoms of their disorder. 



CLASS L — XTrine of ttthjecU suffmnti from Ac 
Oouf, tH ifhoni the fffiienil heatth had iiaually Icen good 
durin<j Hie inlervalt of the paroxyams. 

In hospital pmcticc thrrc is con:*ideniblc difficulty 
is procuring those co-tcs ; for few patient^ enter these 
institutions for a ^inplc attack of a«utc ffmi, and 
there is often a great tendency, among the labouring 
classes, for the disease t<> awiiino after ii sliort time an 
asthenic and chnjuiu furm ; on the other hand, in 
prirate practice, it is not ca^ to procare the twenty- 



CONDITION IN ACtJTK GOUT. 



145 



four hours' urine, uokes the patient himself takes an 
interest in the investigation. 

Cub 1. "W. It, a male, aged 32, having no viablo 
iepimU of urate of Koda upon the cartilages of the 
Mn or elsewhere, baa occasionally sufTered from gout 
fi>r seven years: in the first attack, the mctatnrso- 
phftlangenl joints of both great toes wore speoially 
■fleeted. At the time the urine vn& examined, the 
ri^t foot and ankle and some of tho smaller joints of 
the hands and the right wrist were inflamed with 
uute gout ; there was also considerable febrile dia- 
torbanoo prcacnt. 

Kmh 31. ISM.— CriM «f 21 boon, 35 fl. dudosi; ip. gr. 1019. 
Omt. 

Anoiuu «f nriea<id inSt bonnoG'fiG inioi. 
Mb wrflJaa vm takm M tb« tin* of th* «iamliuUoii. TL« bluod 
tHUt ttMmH ft» taaui Ui btridi in u(o>eid. 

Cub 2. W. H., a male patient, aged 46. Tho 

tttaek of goat eommcnocd ut night in tho boll of tlio 

left great Uv ; tho oatcr sido of the nuklo oAcnranlt 

heeuoe afibctt^J, ftcoompamod with mucli pitting on 

, ptaMtro ; febrile disturbance slight 

M. 10^ lasx— tTrln* of SI bonn, 49 R. annMa; (p. (r. lOISS. 
Add • N* drpait af unto. 

fjnt atiil pMW<l ilaring tlia wltole da; .- O'SI grunt. 
Fab. 21. — CiIm of SI boons I'' ■!■ '•^if I *?• Sf- 1019. Add. 

(IlieMid«fvb«t*dif -91-84 {mm. 
hk SI — DilM of 31 lorn, 4S ± MBOM ; ip- p. lOIS. Amd. 

tJrioMldet ■baleda]r = 3£'!s<^u*. 
After tM tim* tl>« pallciit kok Mlchieum tin ■ daj or tvo, wbich 
t««4Mnl parpng i Ihi BMdiciM, Lovrrw, tad IMW dkwiiliDU'd 
t ihi Mil rramiiniH" -f '^* "'" — ■ •— ^ 



119 



UBISE IS GOUT. 



F«b. S8, — rriM of 34 hoon^ IS B. ooncM ; >p. gr. 1033. laid. 

Uric Boidof wholo (lnj = 2 30 pttiix. 
Feh 37. — Urine of 21 bauia, 'M H, oanco) ; «p. ^. 1013. Ae'i'L 

Crio acii] of wholo daj — 2''ii gniai. 
Tnm P*b. SO (u Kvb. S3 tlis goulj ■ymplomi Kmluiillr ■d1i«u1«>1 ; 
oait •ftor (h« Ullcr liaW, lilU« dm »miun«d thiui tcaclcmim of lli« 
pftrU imriaiulT inflamed. 

The b]«od of tUi pklicut wu ibowa by aiuljui to eoataia iBa«h 
vdewdd. 

Casp. 3. J. 0., a mild pationt, ogod 07, nufleriag 
fram ncuto gout ia the boU of botb groat toes, and in 
several other joints both of tlie upper nsd lawm 
cxtremiticii. A fuw nodutus of urato of Noda found in 
the ears, but in no otiior [lurts of the body, 

Utj 3, 13Se.— Urine, S4 B. oauoet ; »p. gr. 1031, nt CO* Ffthr. 
Tnrbld ftam ant•fl^ but dtatiug vilb niudoinU hot ; It coatAJsa 
a diitinol tnc« of klbuiuoa. 

Uric neiA in the 31 hoan — 3'76 eniu. 
Crr«, ditto =330 smo«. 

Tbo blood of thii pnliBnt cont&iDed mucli nrio acid. 

Cask 4. J. P., a male patii-nt, ugod 4G. Has had 
sOTcral attacks of gout duiing the Ittst tvii years ; oo 
apparent altcrution of «iiy joint produced by the 
disoaae ; but in one ear a Hingle .-spot of urate of 
soda is seen upon thu helix. WTicn the urino was 
analysed the patient vas suffering from Might but 
increasing gouty influmiDntion, affL-ctiiig Ixjth the 
anUcaaiid right elbuv. During the fir»t three duys 
that tlic examiiiutiunij of the urino wore made, no 
mcdiciuc vnu^ tukon; on the fourth, wluhicum was 
adouuietered, and continued during the fifth and 
axUi days; under the ijiflucnoc of this drug tbo 
inflammation of the joints rapidly subsided. 



COKDITIOS IN ACCTK GOUT. 



U7 



F«fc. IS.— <l<i>Dtit7> SB B. OBBCM ; tp. gr. 1030. 

Drieacid in S( 1ioim=S*lS (RtiDt. 
P«b. IS.— {jOBUtitT, S8 fl. onncca ; >|i. gr, 1030. 

Una Mill in 3( bmn^S'lS gnin*. 
rkk 17.— <JiMiitItr, 43 fl. muoN; ip. gr. 1030. 

Urk ulil in SJ liaun = 3'41 gnjni. 
nk IS.— Qnutitr, !;o &. B-aaem ; ip. gr. 1030. 

Urie Mid ia 2i bonn— t'OOgnlni. 
F^ 19.— QnuiUtr, C9 d. uuucm; ip. gr. 1030. 

UrisMU in SI hoan''3"0S foiat. 
F«b. SO.— Qmutitr, (3 B. onuon i ip. (f. 1030. 
Dri«Mid iQ 2i boun=0'17 gi^u, 
•tbuBM cvqM t« dvtMUd la tbe arin*, whuli wu Mid in 



n* Uood «M leiiad la la rioh ia una tad. 



OuB 6. T. D. il., a mule patient, agod 50 yoare, 
far more than twcntj- of which he has 6i;fFiTi-J from 
govt; several small depttsitji of urate of kwIh ujidii 
Uur eon (Plate I, %ui'e 2], ami many of lhi> nrdcii- 
litioas liavo chalk'likc dopiisits around tiK-iii. On 
tlw 8th of JoDuar)', 1853, wveial jniutu were ^wdIIcii 
sad red &«nii acute gouty iiiflnmmatioii, the noto of 
thu day Ix-ing us ibUuw« : " SwvUiik^, heut, redness 
lad tuuderncn of the dorsum of rifcht hand, also of 
bnth wristit ; otinjiidcmblc pitting of tho hand on 
prpflsurf. Rigtit knco swollen, rod, and tender ; KHl 
kat-v ufiectod in a le^s degree ; poise 100, rather lull 
nd ban); skin hot and muUt." On the 11th the 
goaty pains hud almost subeided, and the joints somi*- 
what moveahle ; pube 7:2. Jon 15th, quibo Irco from 
pain ; pulno C4. Jan. 18th, oorcd. 

On the StJ), tventy mtniins of culchicum wine vrvro 
pnMBbod throe timo) a day, with half a drachm of 

b s 




148 



UniNE IS OOUT. 



magnesia and fifteen minim!) of tincture of opium ; 
the opium was omitted on the lllh after the pain 
had Bubaided. The uriuo under date Januoi^' 0th 
WA8 pns»cd between 10 a.m.. Jdnuary 8tli, uud 
10 A.M., January 0th, and so on for the n-mnining 
day*. 



■Ml*. 






Bii tit- 



RmfUuo. 



Jw. 9 10-S lOli-S Acid. 



10 
II 



28 
33 



IS SO 

13 SS 

14 14 

15 18 



18 
17 



18 

as 



18 M 



1011 

1013 

1013 
lOIS 

lOIrt-E 
lOIS'S 
1010 
101 6-J 
lOlSS 



A|<i<auuc*. 



Would 
■niM. 



Dark tlnrpt red. } 

So dcpoitl BDll f 

DOBlbamn). ) 
Dillo 



ILijIilcr aoloUT. 
Una sold deiTont. 
CImt Tellov. 
Olnt 
DIlU 
Ditta 
Diito 
Ditto 
DiMo 



0-6 

I-T 

£'3 

5-S 
S& 

4'0 
3-8 
B-8 
3-4 



At tho comDienccnieut of nnotlior attack, the urine 
of the same patient wu^ examined before tlio adminis- 
tration of medicine, with the following result : 

Qnikatlty, IT (I. oudcm; »p. gr. 1021. Add. 
Crio ncld lu 2i boun=:0'42S grain. 
Dnrtng unLo Bttii<:1u tbo uriot at tliii (lUicnt olnari g]»« cvidaOM 
o( tlio jimtfiw ot n KRi&U iiuDtilj' of KlIiiiiDeR, w)rn;]i could not li« 
dvtMlcd ill th« Inurnili. 

Tb* blood HM oEimiaed at intcrrali dorisg & period of (ointt jetn, 
■ad jriolded sbaoduioe of ttria Mtd. 

Case 6. B. F., amale patient, aged 38,l)MIBfib«d, 
during the la.it seven years, from five or six nttnelcs of 
gout. No deformity of joints and no nsiblc deposits 



OONPITIOS \H ACIJTE nOCT. 



U» 



of arat« of soda in any part. Fnmi the 16tii to Uio 
Iftth of Janoaiy suffcivd ctnisidtrably fmtn iufluiu- 
mftttoa of the hift knpe, licitli bauds, anJ Hyht grwit 
toe, He urine was uiiiiitliu-iicc-d by mcdiciuc wheii 
the cocamiuationa were made. 



i«lh If.— Crini, SS ft DnnoM; tp. gr. 101!^ at eO° Pnkr. AoIU. 



ir» 



Crieteld 
ittta»rj It.- 

Urii add 
Jaaiur7 IT. 

Onetdd 

JlMUWjlS. 

Crieutd 

Jwwiy 19. 

Dticuid 

n« blocd of Ibis 



fUmlnkUd In tho 21 haara^l-SO gnint. 

— Uriu*, SO B. oiiRcn ; >|i. gr. 1010, Acid. 

tlimiitated ia the 31 liDdti = l'9i gnuui. 
— UriM, S6 fl. OBnoM ; ip. gr. 101:2. Add. 

tUulMtedlntbo-it hoDn = 2-T3 Sjn\at. 
—Ut\na, 39 d. ouDota; ip. fir. 1011. Aci>l. 

tUmliuM Is th« St houn=:3-I4 inliiii. 
— VriiK, 47 fl. onnon ; up. gr, lOOS. Add. 

•UmiuUtd in tlu SI beurm^B'dS gniuL 

falknl WW riBh in oiio acid. 



rCxaK 7. W. F., n male pitticnt, itgod 41, has had 
iover*! attuckA of goat during the lust t«n j-cors. 
SoBoe amall dt-poMits of unite of «odu oro •cen on the 
pafaaar Mtrfocc of Icil indt-x fiq^T, but hodo on tho 
caitSogM of tho ears. An acute attack ia now pus^g 
off (March 27tb). 

IUt«b2T, lUS.— Oiiat, SI t. oanoM ;ip.sr. 1021. AcldlDnacCian. 
M •■ aMbtr eblon, ud dafoillJns a jtUow nnU Mdiiueni i>a 



UtM atad paaad is 2^ hoiawi'Vi gaint, 
DriM OTiUlliaad tndj wtth niUlc mU bwB th* larc* aiuoont or 

A|ril 8.— Baa been fm (ran all amt* irmptenia tm touB dai*. 
Cilai^ 48 i. OOMM •*. p. lOIT. A«iil. CUai, no dtpsak 
tTtfa mM pw«< in tbe 21 hoara = I-3d , 



''Fntu a review of tho results of these cans it will 



ISO 



UBIITE IN GOUT. 



be obeorrcd tbat, lu far as hospitnl patients arc con* 
oemcd, till" daily excretion of uric ncid during a fit of 
gout is iiut ncoessarily increased — nay, uftou notably 
diminished : taking the nveragc normid rxcrctioa *t 
8 grains in the twonty-foiir hours, it will be seen tliat 
in the seven cases just detailed the highest amount 
reached was only 8*13 grains, the lowest 0*425 grain, 
and tho averages of the «evcn oases, H'dH — 3'OS — 
2-58— 3-76— 4-46— 3-28— 3-28 grains, gi\-ing a total 
a\-onigo derived from uU the analy&ca 3-62 grains. 
Several of tlie urines were high coloured, some wcw ' 
turbid from urates, and in others there was a dopo- 
mtiou of crystallised urie aeid ; in a few, tlio secretion 
was clear and free from all sediment. 

Tho above results were, as I have before observed, 
obtained from hoFpital patients, and I ha^'o made no 
anslws myself, nor can I find any of other obwrvera, 
showing accurately tho daily elimination of orio acid 
in acQtc gout among members of the higher classes of 
Bodety, although I have been firequently able to 
determine this jioint in the more chronic forma of the 
disease. I am cixivincid thnt tlio cause of tho prc- 
Talcnt idea that tlierc is always an exceits of uric acid 
thrown out of the Kystcra by gouty individuals, esjie- 
oially in tho acute fomis of the disease, is derived 
from iho fact that, when febrile disturbance runs 
high, tho ronal secretion ustinlly becomes scanty, its 
acidity Is increased, and thcreforo almost the whole of 
the uric acid is deposited and thus rendered ^Tsihlo to 
the eye ; «t the same time, the tendency of uric aeid 



4»in>lTI0S IN AOJTB GOUT. 



in 



to attract the colouriDg Qtfttt«iD of the urine, adds 
greotly to this sppearanco of excess. 

Hartng cstabliiihod tho fact that patients suffering 
from ncuto goat do not excrete an excess of uric acid, 
bat rather tho rerorse, it becomes an interc«tii)g 
yartioo to aBcertain whether this defect depunda on 
■njr dtminatioa in tho formation of the acid in tho 
comuiny, or on ite imperfect excretion by the kidueya. 
This question is fortunately not difficult to determine, 
for in ever)- instance above recorded the blood was 
oxsmined, uid proof afforded that in all there 
existed an abnormal quantitj' of uric aoid in the 
Knnn, thus proving indubitably tltiit tho ntnal organs 
were nnablo to excrete the uric »cid funned in tlio 
qrstem, and, as tho elimination of tbi« ucid was shown 
Id be imder the average, demonstration was afforded 
that tbo kidneys Itad lost, at least for the time, some 
of tboir uraal excreting; power. In many other dis- 
oMga, M of tlto livt-r and aplecn, although the pro* 
dtutian of uric acid may he greatly augmented, still, 
the kidneys retaining their oliminating power, the 
Uood ta kept free Irom this principle. The knowledge 
ef these &cta is of coDndcraUu importance, as it is 
truqitoatiy a&sumvd that the uppoaranco of a largo 
quantity of uric acid in the urino indioatcs that tlie 
bkiud U ountaminatod with tho nmo body, whereas 
m Ttfloctiou it will he at onoo orident that such an 
ocewmieo fiivoun« tho opposite view, for if tbo 
. oxerete 



kidiiojra i 



freely, 



ehaaee of boi&g pare. 



158 URINE IN CODT. 

Another result obtninctl from tlio aboro analyses is 
the fact, tUat in acuto gout the iiuontity of urio ncid 
eliminated ou tiifi'crent days is Itublc to much I'aria- 
tion : in tlie early stages of an attack, tlio excretion 
of this aoid k usually small, it then graduiLlly aug' 
mcnts, oud when the fit is passing utF again dimi- 
nifihc& lu Case 4, the quantity vas grontcst during 
the Grai twu days, but in this instance tlio tmolyset 
were uot uiidcrlaken until tlie dl-scaf^e -wa» abating. 

My prc^nt cxpcriunoe on the subject sbov^c, 
that in thu earlier btagcs of aeut^: gout tho urino 
is scanty, and tho uric acid, measured by the 
tweuty-fuur boors' excretion, diminished ; that the 
acid in thrown out in much larger quantities as the 
diijca»c is pai<»iiig oS, imd thnt tbcn amounts oven 
al>o%'C tho paticnt'M daily avoriigo may be excreted, 
forming the lio-cullcd critical dischargctt ; that aft<ir a 
Lime the uric acid is again lessened, although uot to 
tho extent ohscncd prior to or at the commencement 
of an attack. 

Hie daily amount of urea was estimated, in one of 
the above cases, and found to bo 320 grains ; a fair 
average for a patient on a low diet, llic elimination 
of tiic urea in gout is not affected in the some ratio 
as tho uric acid, altliough I have ascertained from re. 
peutcd experiments, that the blood in the noulc forms 
uf tho diseajtc usually contains a small amount of the 
former principle. 

Sometimes a very distinct trace of albunun is 
present in the urine in acute gout ; this occurred in 



i 



COSDITIOK IN ClIBONIC QOUT. 



1S3 



^ 



two of the Cases abovo quoted ; the pkcnomenoD is 
not, I bdiovo, at all uiminou in tho eurly attacks, but 
as tl)o ducoM UEBumcs s clirouio conditioii, iiitd 
B^ecial]y wluu depoeitfi of umto of soda are Retail, 
then trues of ulbuuion nro frequently observed during 
the Gt, nltliough to thu iutcniUs not tLo slightest eri* 
iaact of this body can be ubUiinod. 

CLASS n. — Urine ^ subjivlf nffrded icith Chronic 
Gwi, ihf Hutjoritif o/ t^tm at the fitne the r-zamiimtioHB 
wtn madt kartttg no ter*/ urg^'nt ti/mptoim, hut gi{(fer- 
inffrom the Mequeim c/ this <iiieoie, a» ghoicn by the 
jmwMCtf «/* coucrttiom ^ urate of t^M in diffenmt 
parts of thf boiijf, and the tltffened and deformed eon- 
ation of thejvinta. 

Canr 1. J. H., a iDsJo subject, aged 4o years. 
Bu had gout fur fourteen yeani ; small dcposila of 
urato of soda jirvecnt on tlio cartilages of the ears, 
but tho joiiiU not do£>naod. When the urine was 
axmiued, ho was ntffimug in the feet and ankles, 
and alM in the right kace- TSo medicine was odtniiu*- 
torod at thv tamo. 



10^ 1U8.— Cnn«, 66 fl, ODDMi I tv V- l^H. Clor, j«Ua*, 
Ml ^tnf tu« lo >>/ dtpcail ; ■ altght tnco of klbuncn iracM. 
Crie Mid la 24 hoan- S'TS paiiu. 
Ik* U«di ewldB«<l mncb utie miiI. 

Cms 2. J. M., a gontletnan, aged 85 years. TIos 
Mflorad fimm goat for fifty years. CoDoretions of urate 
of soda exteuivety diffused over his body; gouty 
I of fingen, duoharguig chalk-liko matter. 



iM mncf oon. 

Im^ UN.-triiM |MMi M I Kx, ^ ^ MIT. M* jritart 

ntariMrflhtMM iMlM |>Md teiac lhiii«U «■ |lH 
MJiilWri «ilh krdmUMM Mid. «^ * fc* iMJBtiauli cn*ih «( 



Cad 3. VT. h., n gontlmun, aged 61. Hm ftaf- 
farad nunv yrani from goot, Kis hondA and Etrt 
tnoch d«£jrmed from the pmKDce of cxtenaire depoou 
of urate of sodm. 

Hsr, lUT.— Ur(*(, fMMiltktt* (* fiw h«w* •AvdiaDcr, oftpli 
Hlo* MiWi •P-F- 10I&. AM ii MMtiM ; lU^llr. (With 
AtMtOjtMmmmim. Vb« addAM «bli Mmckbtfe tdl, 
fHi * bw ■imawfla cctiMU cf srig add, Mt mUmI M oIM 

Ca££ 4. A male pftticnti aged 63. Has aoflmd 
fnm govt for mnDjr yean; nne dcpocits of urate of 
soda Been oa botb cam, but cot olMwlicrc. No activo 
gouty sytnptonu at the dme of the orinarjr examina* 
tion ; arine always pale, and firoo front doposts. 

(MobtrSl; 1019.— CiiB^ 73 4. mnM; ip. (r. 1010. 
<Mob«r 97.— tJiiat, 54 B. oobcm ; ip. gr. I0I3, M 00° hkt. 
Drleaidd Ina 31 koun' nriM^-O'SSgnlm, 
KOTwaUr 4.— Urinf, S3 0. comci i (p. s^. IO0I>, M dO* ^Ir. 
Utje tciJ In SI houfi— 0-10 gnia. 
The blood wu (ou[ul to bo rich ia urio Kid. 

Cash J^. It. 11., n miUo subject, aged 41 y< 
SofferiDg from clironic gout of soverat years* stondiDgj 
a few nndulca of urate of eoda seai upon tJic car 
tilagee of the cars, and on tlie palmar sarfiiocs 



CONDITION IS CHBONIC OOUT. 



lU 



I 



ono or two fingers, near the extremities. No actiTO 
foat>' wymftoTns present at tho time the analyses wi?ro 
, peribrmod. 

t^m, 1817.— 'Dnsa, 43 fl. oiiiioei;ip. gr. 1015. Aeld; pdsEnrolnDr; 
*>if7 lUgbtl; albainlnaal. 
Oik wM ttpu th* SI boon' urine ■mouTitfil to ob\j b Tow mieto- 

Xwij otbor examinatioiit of Uiii pal£eiit*> nrins *<ira mide trithio 
■W 4MUM at U>c (dUoving month or >ii week* witb ■ like ranilt. 

It vu in this patient's blood, at the time above 
ntcmd to, tliut I first disoorered the prcsoocc of urio 
■eid ; from it also I was enabled to crystuULso urat« of 
•oda in tlio form shuu'u, Plate 5, &g- 4. 

Case 6. S. It, a malo patient, aged '4<'i years; 
has euflured from gout for more Uian ten years ; do 
|iont* c)f urato of aoda obscnrod on the ears, and some 
di*toTtio» of the handa. 

CriM, US A. oniMt; ip. gr. lOH. CItor ; uU. 
VoadoacUoMU taoUalntdfroDthBoitln!! hnurt* nrin«. 

Cask 7. TV". B., a malo patient, aged &2. Has 
snifeted from gout for many years, and is much 
ddbvmed by extensive deposits of chalk-stones, the 
joints al«o much i^tilTcncd and di^rted. Pain and 
tenderness of difTeront joints almost always present, 
and UkoviM gouty absocsacs discharging ohalky 
outttfT. Many ezuunatioos of the orino made at 
dtffDnmt periods. 

iH>WBfcw, 1819.— ITrini, SO fl. mnMi. Fds. AmO. 
Olia My atalasd &M llw X4 havn' nriM-O'S cnu. 



IH 



UEINE IN GOUT. 




DMCmboF 9. — Urbc, Sii II. ouu^ni ; ip. ft. 1011. Acid. 

Cne Mill ia 2t huun mnonntcJ ooljr to a («v nucrcMoida 
orratoia. 
December, IttlD.^Urino, CO fl. ounce*. 

Crio oeiil, from 3J Uotirt* uHur, nol La lUlEGiMii ijDuili^ (a 

P«bniftrj, ISSO.— Crln«, HO fl. ouoon. 

Uric luiil, from S4 lioun' arim, ■momitad onlj Ic & mete Inoe. 
In alt tbg ciUDiuilloai of lliii [uilJDat'i uriac, n dMant lioct vf 
ilbumM *u dctecuU. 

Case 8. D. M.. a female patient, aged 39. Of 
Sparc habit ; although the tir^t attack occurred three 
jrears siucc, she is already cxtroutt-ly dufonned Irom 
Iftfge chalk-like dcpa'dts about tlio bauds and feet ; 
somo of tlie joints moro or loss 8^^-otlcQ and painful. 

1349. — Urine, iLmouiit nut iianniaiD<iil ; jaIa ; iii-i<i ; up. p. lOtO ; 
■lighttj &tbuniiu(iiu. Whin IrwUU wiUi lijJtusklorio mU it 
jisld«d Utf ttMc of uria lod. 

Case 9. W. 'hi., u male patient, aged 52. Suffered 
many years &om gout; at present has considerable 
stifhesa ut' juiitb^, aud duposits of urate of »oda Dpoa] 
tbo cars and elsewhere. No active symptoms present] 
during tbc time of tlio urinary examinations. 

March so, 1353,— Urine, 3S &. oaneci; ty. gr. lOlfl. CUmt, jiUowi 
not gi'ing line lo uif deposil, bul fielding dietiool tridoBiM of tbt 
jnoMQCe at ilbaiuen. 

Uiie ucid ia 21 honnoS'S gnun*. 
Tbii pttienVi nrinD wiws ouuuinal on rarioos ocouioni daring Aa 
«<wne of nanj jfoun ; It fnqueatl} gart bat a men tncc of orio uni, 
bat aoiD? alt'iiinrii «ualwKji< prvavnt. Tho blouil wu aim uial; 
uid fuuod chiirgad with the aric ooid. 

C-tfiE 10. "W. F., a niulo patient, aged 38. Has 
had acvcrol attacks of gout, at firat iini)iicating only 



CONDITION IN CnnOSIC OODT. 1J7 

the ball of the grrat too, but oftonrards affecting tho 
joints of both upper and lower extremities ; o. few 
spots of unte of aoda seen on tho palmar Burfaoeii of 
&e left index finger. No rcUto symptoms present 
when the urine waa .submitted to cxamination, and no 
medtciDe taken at tbo time. 

Haj II. ISSI.-FriD^ US fl. onsMi; (p. gr. 10!(. Add. ^'o 
^podt. If o al bpnivii. 

Uri«Mi<) ID tin 2t li(iim = 1-3( grud. 

Dtw, ditto ^SaU graliu. 

U^IS.— Cril■^ 33 d. «iinen. Acid. 

Drte (cld In Ihs 24 haani=0'7G gnin. 

Drta, i)Ut« =333 grain*. 

Htf IS. — DHmi, so fl. oniMa ; tii. gr. 1025. 

Trie Hid in Die 31 hoan tuo small in qtuatitj to 
wti|^. 

Ura, Is Uia S( boani = 3l< gmlni. 
Ugf l$.—Vtiae, Zt-i I. onnMa ; >p. fr. lOIH. Add. 

Urit idd ia the 31 liaani b Infc only. 

DrMt ditto =SiS gimiBa, 

Ibad ftWkJ 1* «mhlii mneh nrle aeld. 

Scarly four years alin the abnvc ditto, this patient's 
oriaD WU.S iignin examintn]. At tho time of the first 
onalynH tlie gout}' attack vas pas.>ting off; iilicn tho 
•oand was m^de, he waa quite free from aetivc 

^PIDptOIDS. 

Mcnb 3S, lUI.— CiiMy 31 A. miDoa : tp. gr. I02(. Ao!d. Of an 
ambir osloor, and dcpoiitiac jvllov un>la on cooUsfr 
CriaMUpMNd In lb* '21 lionn-S-20 (nliw, 
ApfU 8.— Driai^ 49 ^.onnna; >p. gr. 1017; and (iTing riw to iw 

Cria mM f—td ia the 3< bMn^l-SAgrua. 

Cme U. C. F., a mate subjoot, aged -38. ITas 
mattond from numerous attacks of gout for ten yean ; 



IB 



UBmE IN GOUT. 



thu first few wore confined to the feet ; at present h« 
bus tsmoll concrotion.s of soda in tho left ear, and also 
a somi-fluid oollcctiun of the some muttc-r at the &de 
of tho left foot ; some deposits also on tho right littlo 
finger. 

Tho urine was firet examined for fourteen sueoeestTe 
dayi<, ID Jiiuuiiry, IS-^-i, the puliunt's symptoms at tho 
time being very elironic, and tho rtaulte were as 
follow : 



Ju. 



M. 
i 


Qusotlly. 


1013 


BMMlon. 

Add. 




St hdiin: 

IfrALuL 

O'SO 


s 


4( 


lOlS 


n 


tl 


0-OS 


« 


u 


1013 


■ » 


■ 1 


0-00 


T 


87 


1012 


it 


» 


0-14 


S 


to 


1011 


»» 


» 


0-00 


9 


it 


IDll 


tl 


•* 


0-00 


10 


u 


lOlS 


tf 


>> 


0-71 


11 


34 


1014 


t» 


■1 


0-09 


IS 


<il 


1013 


*t 


II 


SIO 


13 


£S 


lOlS 


>• 


(I 


o-oo 


14 


67 


1009 


>• 


11 


0-00 


IS 


61 


1011 


tt 


n 


000 


10 


TS 


lOlS 


r> 


» 


000 


17 


S4 


1DI4 


r* 


>t 


00 




The oxpsriments were again repeated in Fcbnuuy. 

F«b. 1&— UriD*, S7 d. omiwi •!>. gr. lOISf, al SO* Fklir. Add. 
No ftlbmom. 

Dria a^ eliniuted ia 24 hour«=I*S2 piin. 

Um, dittu =411 gnloK 

Feb. IS.— CriD*^ CI fl. oancM ; ■)>. gr. 1014, U HO' Pahr. 

Orin aind «liiniiuit«d in 34 boors = O'Tl gnia. 

Urc*. ditto =Wi gnio: 

FcbnujSO.— Crliu^ 74 Hawmi; ip. gr. 1010, at CO' Falu. 



CONDITION IS CHKONIC GOUT. 



IW 



Dtk uM ellm(mt«d !a21 bnura^O-OOgrmia. 
Orw, diuo =3itf gfaiM. 

WJbntaj SI.— UriDc^ 60 9. oanna ; >p. gr. 1(115, »( QO* Pahr. 
Crio mU slbunMed in SI houn = 3*iIS gniu*. 
Ofm, ditto ^3St eniai. 

t blaod of UiU pMint wm tauni to canbun ranoli nrio uiiL 

The mine was onco oxomiticd when this padent 
wai under tho infloonce of cokhicum. 

Itutuj so.— tTrine, t§ A. onnoo ; rp. ^. 1017, M SO* F>lir. 
Uric ««U1 tlimliutWd In 24 houn — no lnu». 
Dn«, ilitto ^2S9 gniat. 

Ctxt 12. C. F.. a male subject, aged 3-5. Has 
had a tisv attacks uf gout ; somo sUglit, but Uio last 
Tory Bovcni, iuduc&l by a serious accident. Iijinull 
eoDcrutioiui of urate uf ewla noticed in the cars, and 
■round 80100 of tbo jwats of the fin^ra. Ko acute 
nnu[it(niiB preeent when the uxtumualiuiui of tbu urino 
vctv mode. 



iM.ll,ariM5T<.u.; *p.Er.l012 ■IGtf'Ptbr. 
. M ., 51 .. .. 1013 „ „ 






M 



, lOU 
, lOtS'S 

siiea«iiL 



Hone of the ipc~ 
eimciu pro U17 
deposit of urio 
uld wLoii toida- 
lalod with hjilra- 

j ehlorio acdd, Rnd 
•llovfd to ilaiiil 

\ 48 bann. 



Can 13. J. P., a male patieQt, aged 43. For 
dtfrm years he has been sobjeet to frequcut attacks of 
d^uat, at first oonfiuDd tu one great too and ankle ; two 
■moll deponts of urate of soda seea on the cartilages 
of car*. No active symptomH present when tho urino 



I j»ifm»im i 



led. 



ISH 



OBIKE IS Gonr. 



J«&«,lU4,iB4Bft70a.«M.; •p.p-.lOia'f n« Ihiw n«dMM 
nn Kt ini i -J MMsUled *ilk »Mt*- 

" «?■ " '■ « " " ift I*''***' "^ "-^ 

„ SI, „ „ M „ „ 1011-[^ti>eBa(BrkMid. 

TU Uool ■» lUt lint* WW tkh b ari« uid. 

After two yMn' intorral tho same patient's nrino 
was Igwa Oxamlncd on reoorcn- from a slight 
attack of gouti and when no active symptonu were 
prceoDt and no medicines odminiiftcrod. The oxunina- 
iiosu vera made chiefljr to ascertaia tba amotmt of 
uroii Bliniiiuted. 



F«bra*r7 », ISM. 


Um,liiiU 


!lb(«ii=lS4tniM. 


*> 


a*. 


It 


>■ 


t* 


-an 


B« 


» 


3*1 


II 


•> 


• » 


-Ml 


» 


It 


M. 


*t 


i> 


, 


<=9M 


tt 


n 


*T, 


If 


• B 


Bl 


>»• 


Bl 


II 


28. 


ir 


>• 


« 


=>>1S 


II 


M 


». 


n 


t* 


BB 


^M>a 


M 


Uanh 


% 


t* 


" 


B 


-91S 


t» 


IV 


3. 


>■ 


II 


• 


-s« 


Bl 


tt 


«. 


*» 


tt 


H 


-2<t 


Bt 


11 


<L 


«■ 


f* 


1 


-su 


It 


»t 


7. 


M 


It 


1 


=.S87 


t» 



Oa maal «f llw abon day* U* vria* wm tnMad wilt fcj4rto1il«ria 
ktii. In m4w to Mewtols tbc mmmnt of on* aoM, but on db onuiM 
WH nSaUnl qoaniUf pcMlpUaMd U Mdeet iMd «Mcb ; in hti, mHj 

fw IBiBTawipie cryiUli «mU b* dMMtad. Via blood at Ik* MM* 
Ub« eooUiaoil a larst aaoaat of Drle asld. 

Cue l"). T. 0., a malo subject, ngod &7. Oont 
of about tw«lre yous' standing ; wry Uige ooooretuHu 
obwn'ed upon tbo eortitagiKi of tbe cars and in other 
parts of tbe body. 

fbpUnih(r, ISft.— CriM Jtir, tt lov tpMiSi (lanli, vith a tnoo of 
!»■ ; wbao MUaUud witb b7d»cU*aa acid, (art k »k« 

iMbuikuU. 



CONDITIOS IN CHRONIC OOUT. 



1«1 



16. R. W., a male patient,. Hgcd 6S. Had 
vaflned from gout for fourteen j'ears, Uie first and two 
eobseqaent attacks vrete confined to the bull uf left 
'great toe ; other jointA afterward.1 beuiuno iiSi-ctcd. 
Has oobG«d dcposita in e«trs for at Ica^ seven ycnr«, 
which are now very large, and numerous spots of 
urate of soda ar« aUo sevu on kfV lower eyelid ; oon- 
•adnnble ehalk-ltku mossps exist about the hands 

and rlboTM, which arc thcTL-by much duformed and 

^H eripiJvd. 



Jtam, ISSl.— tfriM puMd M 13 ■( aoan, up. p. 1011 : diaUaatly 
•UvMinnya. TtmImI >iUi Ljrdrocblaria uid, git* no tnes of 



Cjuik 17. T. F., a geotlenan. ugod 64. Has bad 
fur twenty years. At Brat coniined to the ball uf 
ooe or other great toe, but in course of yearn gradually 
tmTolltu]^ upwards. Is now suficriiig from chrooio 
poilM. and has aotne ealargemeDt about. the fiogcis; 
ooo of UiMO, on being punctured, gave exit to a 
ercaiiiy fluid, coiiHtsling of crj-etallised urate of soda. 
Jio dviuflit upon the curtilages of ears. 

Vtiaa, S<> d. awieM ; pale jrilo* ; cp. gr. IOISl 
Ra k«M «f atie kkI whaa Kinluktcd aitb hjritrunhlario add. 
Oo anoUiar ommw, tb* unnc il Lbl* palieot pin a nvJtniU ilvpoait 
«f wta *eU wIms InaUd ta Ibc laiiio >u«ii[i*r. 

A ftlanco at tho fbre^nn" analyroa will at onc« 
•bow that tfacTo is a murki-d diminution of tho urio 
in th« mine of patients sutTcring from ehronio 
jpmt ; in no omb did it cxcoid 6*78 grains, and this 




les uuiifB m oouT. 

on one day only ; tho next highoat number represent- 
ing tho elimination of uric aaid is S'-W fn^ins, and 
even sudi appeared to bo on a Tory excoptioual day, 
the excretion of this principle being usually much* 
smaller ; tlie total average of all tho analj-scs in this 
second cln»» of c&sfn is execedingly low, for under a 
single grain. Several urea determinations of these 
urioefl were likowine made ; four in Case 10, where 
the qaandties were found to be 306 grains, 33-3 grains, 
344 grains, (ind 358 grain?, giving an avonige of :J35 
graina for the daily oliioination of this body ; and it 
wtti be noticed, on looking over tho details of the 
analyses, thnt, nlttiough tho quantity of urea romoiDS 
nearly oonstout and about normal in qusntity, tbo 
uric acid is not only exctiodingly deficient in lunouotf 
but subject to the grmtcst fluctuatiumi, viuying in tho 
four itiyi from I'iM grains to u quantity too ^mall to 
bo collected and wctighcd. Again, in Cui<ti 11, fuur 
dctcrminntiuDS of tho urea give 385 grains as thu 
daily nvenige, with but a slight difference bdwocn the 
mcMi auid extremes, tho uric acid during the soino 
period exhibiting the same %'ioli;Dt variations »s in 
Case 10 ; namely, from 3'6A grains to 071 griun, and 
on nuotlicr oooasiun fn)m 2'-! gruiiui to 00 gnuu. In 
Ooso 14, tho urea was determined, with one exception, 
on twelve succesaivo days : tho avcn^ wa* found to 
be 286 grains, the extremes being 213 grains and 
359 grains. On oeTerol of Uie above occasions an 
attempt was made to estimate the uric acid, but in 
DO analysis was a qmuitity fuund sufficiently laige to 



CONDITION IN CnilONlO OODT. 



109 



onllect imd weigh. From thcflo obsenrationa it is 
erident, that in ciises of obmiuo gout the funclioD of 
the Iddneys for excroting urnt &»iii the bluod may 
ranBin intact, at Uio same time that the poivor of 
eHminating uric acid muy bo serioosly impaired. 

Another point of iotereet Hhuwn by these examioEL- 
I fioDs is the fact of the fri«quoat proscnco of a small 
\ munint of iilhtinicn in the iiriuu uf chronic gout. lu 
, ten out of Uio soventeoii eaavs it in stated to he 
tlvaKDt, and it is potMiblu tlmt in same of tbo remain- 
ing seven it might hare existud, as its uhseiicu in not 
always ttpuciimy uwerted. Tim quantity of iilbumon 
ii not usually large, hut sufficient to give a {lintinct 
kuinem. when ttw tuine is buik'd witli the addition 
of nitric acid, and also a notable precipitate after the 
tobo w allowed to remain at rest for a sliort time. 

In conclusion, it may be stated tliat the more oon- 
IttKiu appoarancGS and obaractera of the urine in dironio 
ijot, as ahown by these and other cxamiuntions, oro 
blluwa: — 

It a ratlier paler thou healthy urine, of lower 
f, and iucrvnAvd in ((uantity. 
amount of urea, except in exln-mc coi^ixi, 
ItvmaiiDt much mt iu health (due regard being tukcu uf 
[thir diet of the patient at the time). 

Tbo uric acid is rery much diminished, and liable 
to bo excreted in an intermittent manner. A HOiall 
amount of albumen is frequently present. 

Tbo occurrence of deposits in the urine is not com- 
Imoo : they oooasiunaUy ooour during tlio oo<4itig of 




104 CRINR ly OOUT. 

the fluid, either in the form of urate of soda, or as 
rhoiuKs of urio acid, more or less coloured. 



CLASS in. — Uii'ne of inHividuaU mifffring ocat- 
tionalitf/rom attacks of Gout ; txamiwd at tlu time of 
eompUte freedom from sifrnptomx. 

Cask 1. — ■Tlic first thrco analyses wore of the urine 
of a gentleman, 40 yeiirs of age, rather tiiU nnd stout, 
subject Ui oocosionul attacks of gout in tlio ball of tlu 
groat toe, but having never hod auy other joint ftfiiDotcd; 
health otlienrist- good. 

Jmhutt is, 1SJ3. — Criuv, 41 '£ A, oancrt-. iilair, &mbcr ectoiiT ; me\d ; 
■p. gr. 1031. Bt (tu* P«br. ContaiuB an ftlbiuuoD, xd<1 tint rim 
la ao deiHUiit on ooolinf. 

Uriawid (liniinaMd in th« SI liiinn = 4'7! Kniu- 

Jtanuyt?. — Uiincv 13 fl. oansa; ap. gr. 1t1!2. Add. Oim riM 

to a liKht piokinh oalonrvd d«paul <>r nnk* on OooUng. 

Crie vM elimiuiiWd in Ibu 'H baim = 0'llO gr^iu. 

JaDiurj SI. — Drlne, 17 i). uudcm; tf. gr. iO'iX CIrar, »niba 

ooloorad. Na ddpnsit on ouuliiig. 

Una Bcid vUiniutsd in tha 14 hnuia— 3'Sf gr^hu. 

Case 2.— A gcutieuiftti, aged 56. Ha* suffered from 
gout for many yeart, nnd hii.-' ha<l the larger joints of 
tho body affected as wdII iis the great toe. 

Fobnui? 13. ISSl, — Crine, eO 1 oomm ; tp. gr. lOlt, mt CO* Pifaf. 
Pre* Iram tlbamcn. 

Crin flclil cliulDotixl lu tho 24 liaun= i'SS grstna. 
A MDtll bliiiMc api'llvl at annlhnr prnud yielded ft fliud *bidt oo«- 
UiMd ft ooiuidentils ftmuuBt of niio acid. 

Case 3. — M. C, a Indy, about 38 years of ago, who 
had suffered &om atonic gout for many years, but ia 




CONDITION IN THE INTERVALS OF THE FITS. I« 

five from any «xt«miil deposits of urat« of jnkIu, nod 
from dcfimnity or rtiffitees of joints. 

Mm, *i I. MMM : l«b in mlaur ; on ■Iboniai ; ap. p. I0I9, ii 
Wfkkr. 

Trb elimiutol ■■ IW SI boanaSfS gr^niL 

Uric KiJ, dlUd, DO tnw dcponled. 

7asb 4. — J. L. B., a male subject, agod 4S. Has 
from three attacks of goat, the great toe being 
•fprcially ufli-ded in each attack. N'o deposit of unUo 
of aoda visible either upon the cartilages of the ciirs 
m may other part of the body. 



r 31. ISII.— OriM, SS S. onsoea : ip. gr. lOIS, itl tO* Fibr. 

Driticid diminUsd la Ihe 3< bonn-^SilS graini. 
F>(cMi7 SS.— CriMt 8Sfl. oonen; njt. gr. 1080, at SO* filiT. 

Uric acid «UiiilD*l«d ia tlu 21 1»iun= 1-23 gntn. 

Vtm, ilitio, ==S8JI grilna. 

Mnaiy 31. — Xtnar, 90 I. oaaR*; iji. gr. lOM, at 60* Fabr. 

Prio Mill cJimiiiatail in Lba It lioiin = l'$l erain. 

(J(Mt dilU, =SSi graini. 

' 95.— Ciintk 77 A. ounno ; tp. gr. 10)1, at SO' Pabr. 

ITrio mM aliwaalcd in Iha 34 konn — 1 'K9 enin. 

Una, dlUo, -S'O gruni. 

Fabnai]' ST.— OrlM, 61 fl. oanea* : (p. gr. 1013, *l dO* Fabr. 

rrie arbl ainbalad 1b tba S< boura = 0)9 gnin. 

tPna, dKH =33S gniaa, 

TW Uood Ukta dning th« Gl vmi foiiail riob in nric Msd. 

At the time this paticnt^s arine vas examined for 
and aric acid, it was clear and free from deposits, 
dnring the attack, which was very Ecvcrc, the 
Brtoe became turbid on cooling from the deposition of 
red urates ; no albumen was present at any pciiod. 
Case A. — T. B., a male pntiont, aged 6-1, had 6uf- 
frtiin numerous attacks of gout, chit^y in the 



IM URiiTF, IN onrr. 

groat toe ; no <I?])Osit« of urato of sodit visiblo in any 
port- He was free fruin iill symptunu. nnd had 
omitted mixlinui's fijr some timo beforo thu oxmnina* 
tions of tlio urine were mudo, but a fow days after- 
wards Im hod a return of f^iiut. The patient was 
idlowvd 11 moderate amount of meat 

May 11, l?r>4.— Drinis 10 ll. ounm* : olMr ; Mod ; «]>. sr. 1019. 

Drio oaid utimituLU<l in thv 24 hoan, — ■ mera tnco. 

Viat, ^itto, =S78 gniiiM. 

U*j 12.— UrtDO, CJ 11. onnota ; nold ; >p. gr. 1017. 

CrioMiil v1imiiiat«il in tlio2'l hnun^—tooiuaJI (QOuUMtauJ 
■ugh. 

VttD, ditto, =4f1 gnint. 

SUylS.— VHncTI fl. Muieat: tip. [r. lOlC. 

Urio add olimiuaUil in (he 24 honti, — a nuire traef. 

ITna, ditto, -sue jjtsiiu. 

Tbo KTuiQ of Iha blood ciamiDcd dnriDg the attack vai fonod lo b« 
ridiiu itriateU. 

Casr C— S. N., a male aubjoot, aged 68. Had 
sufforod for mimy years from ropiiatod attacks of goat, 
chidly in Die i;rcat toc«, but other joints have uocu- 
sionttlly been uffcctt-d. 

F>bniai7 SI, 1364. — Urine, t>0 fl. oanov* ; up. ci. 1013. 

Uria uid ditpinaUd in the 24 hoan^rss graiu. 

Una, ditu, =317 gn^t*. 

Polcunnr S2. — CrJno, SO l!. uunnca ; *p. gr. 1014. 

Urie aalJ tUniuaUd in llie £4 houn = Sii'9 nraini. 

Urea. ditto, -S13 Etuioi. 

P«bruarT 33.— Urinv, 44 A. oniifw ; <p. gr. 1014. 

Urie aoid tltminatcd in lie 34 lionn- I '60 grain. 

Una, ditto, =i76 gniot. 

FtLiruarj 'i*, — Urine, SO II, udhom ; up. gr. lOIS. 

Urio aciil eliaunalud in llu) 34 hunn = I (S erain. 

Urt*, dittos =331 graina. 




ooKDmoK IN THR i;iTP.Tiv.u,s OP Tint nts. I« 



tiibntrj tS. — Drine, 40 0. tranoB* ; ip, zr. lOll. 
Dri» leid climinjitoj bUiv 24 Iiaim=3'73gn^(ii, 
Vnt, >l>tto, — 3S0 grunx. 

TbiH patient had talcen tanull dofcs of the acctto 
extnot of colohicum la the form of pill for Bevoral 
iay» previous to the 21st, aiid on the 22nd was ordered 
to omit the Arag, on account nf the ocourreoix.- of Elight 
diarrfauKi ; this continued moro or Wsa till the 35tli. 
From his own statemrnt tlicro was no toss of arino 
durin); that time. 

It will bo Hei'n from the above fiascf< that in no ono 
nf the ax patienbi did the amount of uric acid cxcrotod 
in tfa).- twenty-four hours exceed the healthy avorngc ; 
in the majority it was far below. From tlicso and 
other loGH oomploto vxuminations I am inclined to 
■ Ihiuk that in indindunls who hare suffered frequently 
frrim goat, oven though no \'i.tible defurmity of the 
joints or deposits may liaro nr^-iulU-d tht-rcfrom, the 
kidnoys low to some cxt4*nt thoir pi.iwer of excrct- 
hif orio «oid ; moreover, I am convinced from the 
IHolto of many trials, that the blood is often kept 
trnpofe from its [neseiKe. This is probably one causo 
oT tlie extreme liability of such patients to periodic 
visitations of the malady, and also of the great diffi- 
calt>- iu efrc<;tiiig its radical cure. 

It is hkewiso intereeting to obscrro that in thoM 
uuHvidoalis OS well as tn those suffering from ocuto 
or chronic ^out, the tuea-eliminating function of tlte 
kiduuye r«matn« comparatively intact. 



I 



l«l 



UBIKS IN GODT. 



Miemei^pie tTaminatton of the UriM in Oouf.—Tho 
uiins of gouty puticnts somotimc.'i cxliibitt micTOficopic 
fihaiactCTS of great raluii m arriving itt a onrrcot 
prognosis of the disease. lu tliG early stages of gout 
occnrriiig iu individuals ollierwLsL- Lealtliy, lbs iu- 
fbnnatinn obtainEibtc- ftom micraHcopio exnuiiuation of 
this fluid is of little moment. The urine, perhaps, 
exhibits a deposit of urate of sidajvamiig in hue from 
a pule LufT to a bright pink, or brick-du.st rod, and 
consisting either of amorphous granules, or masses, or 
groups of epiculiB ; or there may he sediment* of urio 
acid; or the two may be combined, as seen in Plate 6, 
fig 1, and fig 2, a, b; hut an thcRC are frequently 
noticed in other diiM^ascd condition.^ of the system, the 
infcirmatiuu tlicy afford is slight. When, however, 
the uffeetioD becomes clironic, and more e^iprciaUy 
when extensive dopositjt are fnrming around the 
jmala, then other phenomena are frequently obwrvod. 
Along vitlt the Kmall amount of albumen which wc 
have found to be so oommoD, casts of tubes arc met 
with, generally of a grapular character, m exhibited 
in Plate 6, fig. 6 a, and consisting of dinntegreted 
epithelium, more or le.is moulded into the shape of tlic 
tubes. Sometimes tliese arc seen during the acute 
esacerbatioD, but not in the intervals; such was the 
case with the urine of two patients recently under my 
care. This appearance «f granular casts, indicates 
tlint a desquamative process is going on from the lining 
membrane «f the uriniferoa^ tulip's, a change closely 
connected witli dcficioat secretion of some of Uic 



MICBOSCOPIC CirARACTERS. 



]« 




ekoHMits of the uriuD, luid more espocuUly of tlie orio 
add. 

When the disease is still further adranced, a con- 
liitioD amxmonly eridcnocd, not ouly ly the fearfully 
crippled state of the pt* 
tieot from deposits, bat 
hbewise by the oceurreiico 
of btbcr more sorious 
synptoou, as epilepsy, 
pant>'8)«, and coma, due 
to itoperfoct dimiuation 
fpjoi the ld<Inc>-s, then not 
Doly docs the urine hocomo 
ppmuuiuntly, thou)fh ]>or- ^^ "•' 

li^« sUgbtly nlbuininous, but the grauulur ca^ arc 
mtm or le«s replaced by othcm of u waxy or 
fibritHiu.*) nature ; those tatter roriii.« are seen iu tig. 13. 
mixed with socuc of the grauul&r variety. 

SoTon] fit the oa«os tllufitrativc of chronic dc-squa- 
nwtivo nrphritis, rdatcd by Dr. Q. JobiiMu.wore tlio 
fubjeotii of chronic goat 

Id the hitter stages of gout, DopieuR depodts of urie 
■eid, or urates, arc not often met with, and tho urine 
breomiitg much brighter and more iintural in up- 
pciLniDce, usooUy improsma the patient with tlic idea 
that an imp rare mcnt id his slate of bonltL has com- 
whercuii, iu fact, it is an iu(licutii>D that tho 




Awwtor. dnvn &ga » ipesiMa kindljr Icot (7 Dr. G. J»biM<B. 
i^BRpovcr, 230. 



I 



170 WBINIC m OOUT. 

excrotiiiK power of the kidneys hfts bocmno dofioicnt, 
ut k'ast for uric acid. 

Wf hare alrcndy alluded to the intermittent manner 
in which the urio acid is sometimes cliiuinntcd in 
goutj' cases. For days, soarocly a traoo niny be 
thrown out, and then suddenly such an amount tat to 
ho rapidly deposited in n frystallino form, when tlio 
oiine is allowed to cool. I^astly, oxalate of lime is of 
frequent occurrence in the urino of gouty (laticnts, 
but as it i» fonnd in m many other discuses, it« pro- 
scnoo is of no value as n dingnostio mark. More eom* 
monly it is found in octahedra, rarc-ly ns dodotuihttdm, 
and occneiunally in tho dumb-bell variety, as shown 
in Plato 6. fig. 3, a, b, c. 

Match, 1862. — Want of time has prevented ma 
from making many further quantitativo analyses of 
tho urino in gout, hinco the publication of the first 
edition of thv present work, hut abundant oppor- 
tunities have been affordod mo of testing the nMuracy 
of most of my former statement*, moro e^cially in 
cases occurring in the higher ranks of life. I can 
p(>i<itivcly affirm that tho presence of a slight amount 
of albumen is very common in tho chronic form of tho 
dieoaso ; in acute gout it is less freiiuent, and oftiio 
diaajipoars after the paroxysm has sul^^idi'd ; but in 
the diroiiic variety, it is usually pcnsanciit, altlioogb 
it may vary much in amount. Experience has oon- 
Tinccd mo of the great importance of iittcniUng to this 
state of the urine in reference to tLe treatment wf tlio 
diaordor. I am no kes comincvd of the truth of mj 



I 



1 




GENERAL REMARKS. 171 

statement as to the deficiency of uric acid in gouty 
niino, and that the defective eliminatioQ gcncmlly 
bears a close relatioQ to the inveterate character of 
the malady. 



m 



MORBID ANATOMY OK GOUT. 



CHAPTER VI. 



Tint MataiP &«*toiit or Gooi ;-~4**4t iHroMAWoi oi thb bvb- 

dh. iioiiiio. mil uTUKiu — ^iiu a. iKni>[E'a t>ini:m"ii or * 

OOtITT (tUECT — cnVTKIUnXK'* OOS««TiIIOM— TUl iOTMIl'l I 

iivuriattiuiis — 1. etAxa or onsniia oodt with rxttsnTi^ 
CHILI. iiTi.BW ixv visTuRTioiB — 9. Huuivn rxnuirnia roim 

Iir I>Ii»C[T|i>N uH TIIB UM lI'ilIK — 3. !*««• IK KlliCn M 
hirciBIT cjU Oir^lRHITT EIIKTKD—l. Vlln OKI-T THE BlU. OV 

bRK UNtAi TuK iiAi> umn Arrwmti with ohqt— &. wiikr a 
■tuoLN ATTACK or MKT ■*!• iKDiiuap Mirt rtjiu rMviuvni. 

It is commonly romarkctl, in wnrks devoted to tbe 
oonsicleration of gout. Dial morbid annUimy has flfnct<Ml 
little toward" the cluridatiou of tho nature of tho dis- 
etiso ; tiiat ultliuu^h alteration!* of struuture bare been 
found in many cii.«os, ^till thi\«c haro licun iiLmflicical 
and too much wanting in constancy and preoi&iou to 
be depended on. 1 liDjn-, liowevcr, to bo able to show 
tliat at the present timo this remarlc in no longer correct; 
and that the study of those chungivt, which I shnll 
demonstrate to be conntaut in all cil^ck of the diticaset 
throws conndcrable light ujyon tho true nature of goat. 
Considering this part of the subject of tlie highest 
importanci*, I shall not hciiitiito to devote considcTabIc' 
space to its iuvcstigaciun, and sliull cudoavour to pro- 
sent to tho reader all that is importaat conocnung it. 




i 




^ 



I 



^ 



ORKAT IMPOHTANCB OP ITS STUDY. 173 

portion of which has oiily been Hutixfsctoriljr 
proved withiD a wry inccnt period — I aJludo ci=pe- 
otally to the c«rly chungcs of structuro in the joints, 
and to the frequent or ulmoet oonstant affectioQ of the 
lodocys. 

It tuu l)Ocn long ksovm that choo^ in and 
around the juint« occasionally ensao in gout, oiising 
(rom tli« deposition of u chalk-likv mutt<.'r, principally 
oompowd of oruto of sodn, biit this phi-iioDii>non has 
genenlly been looked upon 8^ ratliiT cxccptionAl, and 
18 oocorring only in individuals who luirc HuJfered from 
tlto disease in Us moot invctorate And protroctctl fonns, 
and no tdiw was entertained that any neeessarj- rda* 
tun existed between gouty inflammation and such 
dopoaition. 

M. Portal, in hifl " Anatomie ll^dicalo," as<mres us 
he has seen the sjnorial secretion of the coDsi^itenoc 
of jt'Ily, or even sometimes so tluck as to have the 
appvoranoc of plaster ; ho also observed, after pro- 
longed and severe gout, the bones of the feet oovertd 
with this white matter. Itorgngni relates the same 
io bis account of the examination of the joints of a 
Yonetian nobtemao. 

Dr. Monro, Jan., in hts "Oatltnes of Anatomy," 
nnariu. " Tho extremities of tlio bones of the foot 
aoi hands have bc«n said t'> be- iiccii^iciiiully converted 
into a whilu sub«tunc« like chalk in purrauis who have 
been long afflicted with gout." and in tho first volume 
of tho HfMJirffl Communication*, 1782, Mr. ni-nry 
WataoD nlato th« appuaranoc^ found in the body of 




I 



m MORBID ANATOitY OP OOUT. 

an extremely gouty subjoot and woU koovn chnnuitcr, 
a Mr. AliddlctuQ ; tlio most impartunt poiuL* of LU ox- 
tuniiiattiiu am as folluw^ : — Uuc of tin.' gri,-ut lutx was 
mucti CDlargcd, Aud oii disHUctioii tliu bull or first joint 
was fuund, as if encased iu n bod of chalk, like u fossil 
shell, but the bone it^ilf was neither increased in sizo 
nor idtcred in structure. The juints of t]ie fingLrs 
were iiLsa swollen and knotty, cueh knot being u lump 
of elinJk, and, when be played ut etirds, he n»od 
frequently to score up the game with his knuckles. 
On the middle of the right tibia there iiiiiRured na 
oblong tumour reaonibling a node, over whivh tho 
intcgumcnbi were very thin and ready to burst; it was 
a mere deposition of chulk between the skin and 
periostcom, and though thick nud large, hud not as 
yet done itny injury to tlio bone. 

Ur. Middlcton had comiiluinod uf excmciulinj; pains 
in his houd, uften iniLigiuiiig he was tuiabliuj; hi-dd- 
long ; tlus was especially tho case a little before bis 
death. The dura mater was found indurated, tho 
8ul)«tanoo of tho brain firm, with a clear fluid in tho 
%-t:iitrk-le!s; llie piu miil«.T wua p:ile, imd un its outer 
sorliice was a ereuni ur saiixitli eJiulk-like mucus. Tbu 
heart wod healthy, and alsu the thorucic itorlu ; ttm 
aorta, howcrur, was ussilied triuu the diaphragm to 
the iliac arti.'ries. Tho kidneys were much diminisliod 
in size, and contained hydatids, and the outer surface 
of tile right was studded with little Idaddere. No 
calculi or chalk were observed in the kidneys or 
urinary bladder. 



J 



SIR B. imODIES DISSECTION. 



ITfl 



The sjiioxnal fluid in tho joints of Uio lower oxtro- 
ImttiM van as tliick as crcein, like a inixturo of chalk, 
Foil, and vatcr. hut the vartitiigos wcro cot much 
ksltenxl. 

In the tuhc of one lung a small stoDC was disoo- 
I Tomit and the tracheal ginnds were tilled with whit« 
mnttcr. 

It muiit be bonio in mind that Mr. Watson was 
[tiot at all aware of the nature of the chalk)- substAncc 
BboT« spokoi of, and had do power of ohcmically 
dtftingoishing deposits of urate of soda Irom those of 
carbonate and phosphate of lime, and therefore we 
bare no proof tJiat the white matter in the hrunohial 
glands and the sntatl stone in the lung cuntuini'd uric 
■dd, or were tn any degree related to tho dcjxjsitA in 
and around the joints, or had any cuiiaectiuu witJi the 
gouty dii^eoflo. 

Sir B. Brodie, in 1813, made n dissection of an old 
lady who hod Buffered in an unusual degnt.- frum ^ut 
tor a great ]iurt uf her life, lutd Uiv priiici[iiil [loitits of 
interest, in connection with the prcHcut subject, arc 
giren below. Sovorul joiut» of the tingors were 
uucbyluHcd, tho fingcn thonu>clv<.4 being vutiuusly 
dirturted; the middle linger i>f the left huud was 
abortoned, and tho skiu over it Iuo»c. Tito bono uf 
the aeootul phulimx apiMMUod to have boiii nearly 
abaortwd, so that scarcely any uf it remained, and 
only a small quantity of a soft 8ub«tanco occuinod ittt 
flam- Tho right wrist and elbow woro ancliyl>»cd, 
Bi WMQ alao several joints of tho toos. The knees 




IH 



KOBntD AtfATOUY OF OODT. 



niltDittc<I of inonmploto fl«xion and oxtoiiaon ; nod tlio 
motion of tlio jaintfl wiH attended with ■ grntiiijc sonnn- 
tion. til vsriouji piirtti of tho body Uieiv wcro urilioM 
in tko Hkiu oomniuuk-ittiiig with mombruugtu oyster 
eituntvd in thu udipow subdtaiMW, and disulmrging a 
c-kntky li(]uid. Thcro wmv no ronuuiu of tlio cartilages 
tu tho U-lt kiioo. Thu oOTTeqwnding ]iukrt« of tho 
patrlln iiud OMiidylcH of tlii> fi>nmr hiul thv npjMiar- 
Miuo of huving boon wurn into groortv) nud ridgoa, 
118 if from friulion on onch othor ; pmrnnting, liow- 
OTor, n ooiDjiuot surfiicc, tlie cuDocllons ntnicturo not 
being oxpomd, oa would huvo bwn tlio caw if friction 
bad bct-ii curried t') tho aamo extent in the dead 
body. A Uiin luycr of white chalk-like matter hud 
been deposited on the bones in several pUeea where 
the cartilages had disappeared. On tho margin of 
the articulating surfaces were several small exostosea. 
TIio ligaments and sj'novial membrane were littlo 
altered froni their natural elate, with this exception, 
that tho thin layer of tho latter, which is extended 
over tho cortilagos, had disappeared with the carti- 
lagcs thomsolvos. In the ri^jlit wrist tho first n:iw of 
tho oaipnl bouen were anchylosed tn each otlior and 
to the radius. The other jointu wcrr not cxnniinwi. 

Oruveilhier, in his "Anatomio Pathologiquu," has 
given a plate dcliunuting sonic of thv ai^MHiranoes 
observed in tlio ymiln of a ]>ittieiit KuHiirring from chrouia 
gout. In tht^ knoo-joint tho nmdylcs of thv femur 
were seen Vi bo covered with llie plaster-like 8ub> 
timcc, stated to penetrate to tho bono, and tlto aain e 



CRimtlLHlEirS OBSERVATIOXS. 



1T7 



I 



matter was abo noticed on the oj-novial fringCK. The 
artioulatiug surface of the patellu had the like deponta 
arraogcd more or lew linearly ; on its nntoHor siirfitco 
two enb-cutaneaus synoviul capsules were found, tlio 
walls of wliioli were thick and cartilaginous and 
sprinkled tlirougliout with white points, and the con- 
tained liquid had tlie appearance of nhalk and vater; 
the Gbroos layer oorering ^e patella, as also the 
various tendons, were dmilarly afTeotod. 

In the ankle joint a like incrustation was obserred, 
and depa'dts were found in the two lateral and posterior 
ligaments; the lateral and Ruperior surfaces of tho 
astragalus were aim covered mth tlie white matter 

On making a section of the astragalus, Cniveilhier 
obiierved witliia the substance of the bone, and at s 
small distance from the cartilage, little cretaceous 
masses, which he had also noticed near the calcanean 
Bor&ce of the bone, the neighbouring cartilage being 
in a perfectly healthy conditioD ; tlie so-cn11ed crvta* 
ceons matter was evidently supposed by Cruvcilhior 
to bo of the name nature as the substance on the 
cartilages themselves. Smull inassm of deposit woro 
likewise seen in the adipose cellular tissue, which 
covers the plantar and lateral faces of thu os culeiH, 
and also in tlio tendo Achillis. In tho foot some of 
the articulations, as the ssti-n^o-Bcaphoidcoii, cal- 
oaneo-euboidean, and astragalo-calcanean, were nearly 
£rc« from deposit, but those of the scaphoid bone, with 
the three cuneiform and ouboid hones, and the cuneiform 
bones among themaelros were incrusted, as likewise 




ITS MORBID AtJATOMV OF GOUT. 

the motAtarH)-tiir»i1 artk-uliitiun«, und the mctatarso- 
phiiLungoul joint, or bull uf Uio ^■ut toe. Linear 
(lei>osits of ohttlky iimttor wcrt' swn un the ptiriostcum. 
Around tW mctaturssl bono iind ])hiiIargos, the pha- 
langi>al nrLioulntioa v/aa anchyloscd, mid the cmiilngcs 
appaieQtly destroyed fium deposition. The tendou of 
the flexor longus potlici-s was covered with the concre* 
tion ou botli surfuces, as VL-w were the ligaments sur* 
roundiug the grout toe. 

The thumbs and little fingers were similarly aOcctcd, 
but the intenuediuto fingers very slightly so ; the sub- 
outouoous capsule of the elhow oontaiticd n plaster* 
[ike matter, tlic joint xtaeiS being healthy, but in the 
cellular tissue, along tho course of tl)o biceps, and 
even within some of tho musclos, gruuular chalky 
concretions were found. 

The resulfci arrived nt from the above oxaminatioiu, 
may be thus summed up. In many cases of severe 
and protracted gout, depofiits of chalky matter (urate 
of mda) occur around and within tlio joints 0<><1 upoo 
the surface of their fihruu!* ti-Httue.-* ; the synovial fluid 
becomes tliiek, now and then even of the consistcace 
of plaHter ; the joints are either purliiUly or completely 
anchylosed by the rigidity of tho surrounding Uga> 
menlA, and some of the smaller ones, cepcdally (to 
great toe, occa^onally »o completely surrounded with 
deposits as to eihibit the uppearunco of being inclosed 
in a chalky ca.se. 

The dissections hitlicrto given have bccu confined 
to gouty subjects who luul suffered from tho disease in 



i 




CIIBONIC GOUT WITH CHALK-STONKS. 



179 



lb most «CTcrc and protructcd fonns ; from these alone 
vo sbodd tw quite iitiablu to arrive at any definite 
mnelasion as to tlio ocourrcnoo of any coiistant changes 
daring; gouty inflamuiation. Coii.tidcriiig this a most 
tmportnnt point to dctcnnino iiccurixtvly, I have for a 
bog time devoted much attention to its consideration, 
snd have recently been enabled to oluuidnte Batia- 
&ctonly the real nature of thee« allcrntionH. 

In order to render tJie suhjct-t ns deur ns possible I 
will shortly lay before the rendt'r tbo results derived 
from many autopaes of goutj- subjects, snmo of whom 
bxre died daring the presence of gouty inflammntion, 
noBt however in the intervals, from accidents or mala- 
dios totally independent of gout ; in cororaenting upon 
them I «bull first dL-ecribe the alterations seen in and 
around tLe articulations, and afk'rwonU treat of tlie 
■ dkaogee in other structures. 

L — Eramiitation of tvhjdit of Chronic Ooat, tn'M 

Ca»x 1. — 1855. W. M., a man 55 years of age, a 
eompoHlor by trade, not known to have any here- 
£taiy predisposition to gout, but a brother had suffered 
thediseaM; he had formerly in<!iilg(>d in malt 

lOon and qiirita, and altogether lived rather freely. 
About fifteen years befi>n> his death hnd the lir»t 
attack of goat confined to the ball of the great toe ; 
after a time, the dlfoaso became more general, gradually 
creeping upwards until nearly all tbo jointu nf the 
body hud become implicated ; deposits of urate of tu>da 

as 







UO HOBBID ANATOMY OP COUT. 



had been observed for many years upon the cartilages 
of the ears, and around many of the smaller joints, 
especially of the hands, some of which had approached 
the surface and had been dinchargod hy ulceration. 
Many of the articulations were aachylosed and othcr- 
wiBO deformed, and some of the bursa), csiwciully that 
over the loft olocranun process, wcru much distended 
fixim dopusitiuu of clialky mutter, the elbow however 
was less Kwollou than that roprc'cntod in Plate 2. 
Albumen hud bot-n detected in his urine for some 
considemble time, with casts, and of lato the renal 
affection had much increased and bad heoii aceom- 
panicd with some cedoma of the lower oxtromitioe. 
The cause of his death appeared to have been exbauB- 
tion from the almost constant presence of gout in ono 
or more jointa, hastened by a severe shock to his 
nervous system. 

On opening the left knee-joint, the sjTiorial finid was 
found thiciened, and on close examination exhibited 
minute white specks of urat« of soda. (Plate 5, fig. 3.) 
The condyles of the femur were extensively covered 
with the deposit, not simply arranged in streaks, but 
occupying n large amount of their surfaces, except at 
the outer margin, in the atuation of the synovial 
fringcfl ; the end of the tibia was coated, but less freely 
than the fomur; the articulating suiface of tho patella 
was like«'uic inerusled. 

The appearanco prescutt'J when the joint was first 
examined, i.t acctuately depicted in Plate 3, fig. 1, a, 
b, c, R drawing taken from a wax model mndo at the 



5wl 




d 



CHROKir GOUT WITH CHALK-STONES, 



191 



I time. Till) synorial membrane was very rasoular, 
^^^bd DumCTuos whito f;rAnulc8 could be observed snd 
^^wt upon tbf surface, conristing alw of orate of soda; 
doposils woru liken^a found on the crucial lignmonts 
and fibru-caitilages. The right kneo exhibited iii 
ovm* rcspuct tbo sitmc pcculiuirititiis tti the left ; all 
the Hrtioulatiiig suifacus beiog finely covoKid with 
dqiorit, as vdl M tbo fibro-cortiJagc^ and ligaments, 
and tho same chnngcs were nbscrvod in the aynoTial 
mentbran^ and flitid. 

Many other joints were partially examined, as the 
olbow>joi»t8, al^o several of the cnrpiU and metacarpal, 
: tvsal and metatarsal, and pbalangoal articulations ; 
for the most part the surfa«efl were covered witli a 
white coating nf urate of soda. Tlie ball of each 
grwit too wns completely incruitcd. 

The kidneys weighed respectively 3] and 3 ounces 
aroirdapots ; wen- pale and contracted ; the cortical 
portion shnToIled, poiiit8 and streaks of white matter 
vero seen at the apex of each pjTamid and running 
Dp in the direction of tlic tubuli. 

The nppeanuicoii exhibited by tlie right kidney, 
botli extcT7udly and after wction, are iJiown in Plate 
4, fig. 2, a. 6. 

Cams 2. — J. P., about sixty yearn of age, a ftrong* 
lofiking man, six feet in height, had been a gouty 
patient for many years, with dopoeits upon tho car- 
tilages of the ears and arouitd many of ttic joints, 
some of roiisiderable size. Death was occasioned by 
an aoeident. 



IS2 



MORBID ANATOMY OF GOUT. 



I 



Haoy of the joints wore coated witli white matter 
BS in tho previous case, Tlie kidneys were much 
G<mtract«d, each weighing less tlian three ounces, and 
exhibiting the deposition of urate of soda upon the 
end of cftcli cone, and also in the direction of the 
tuhuli. 

Case 3. — D. B., aged 64, not inheriting gout, a 
man of steady liabits, who had rarely been intoxicated, 
but had been much espnsed to cold and wet. Hewaa 
first attacked with gi^ut when 28 years old, in the ball 
of the left great toe, and has hud numerous attat^ks since 
that time gradually increasing in severity : the disea-w 
was confined for sonit* years to the lower extremities, 
but subsequently the fingers, hands, and elbows be- 
came affected ; he first noticed the formation of chalk- 
stones eight years ago, after an injury to the back of 
his hand. At present (July. 1861) botii ears are 
studded with deposits, the wrists enlarged and partially 
auchylosed, the feet and knees swollen and distorted, 
the latter flexed and almost immoveable ; numerous 
sores exist about the diseased joints and give rise to a 
discharge of pus mixed with urate of soda. 

This patient died worn out with soffering and 
exhausted hy diarrhcea and gastrie disturbance. 

The articular surfaces of nearly all the joints were 
covered with a coating of chalky deposit, and tho 
various ligaments freely sprinkled with it. In addition 
to the parts more usually found affected, it was noted, 
on examination of tho loft hip joint, that the cartilages 
of the head of the femur and of the cotyloid cavity 




CBRONIC OOUT WtTH CHAI.K-aTOSES, 188 

I tt»o Uiickly spread ovor with tlio same plaster- 
like matter, and spots of unit*.' of ttodii, aa delineated 
to ilg. 14, were present in the ligumoDtum toiM. 




^ 



Kg. ».- 

Few minute !ipcok)t of the same nature w^re liko- 
nisL' found on the arytenoid cartilage of the larynx ; 
thcro was mmo athoromatoiLi depo»it ahout tho mitral 
ralvo of the heart, hut no uric acid was contained in 

iL 

The oapmiles of the kidneys were adherent, Uic 
oortica] stnicturo diminished and not easily distin- 
guished from the pjTnmidal portion ; tlio Kuhrtance 
wa« aoft and fatty, lumic gritty colloetioDa were found 
in tlup poiria of tlic left kidnc}', where there was also 
a nmll uric add cnlcultm, about the siiK of a pea. 

* Rs. H. TU bead of Iha fctnot vl t>. B.. ifaowisg th* drposiiun 
af anl* <f xda io the tartil^« snd (pow o( tbi nmr ia iba lii^mmiant 



IM MORBID ANATOMY OT GODT. 

Case 4. — H. B., aged 48, a musician, father and 
mother both subject to gout. For olcvi-n years of his 
life took one pint of port wiiic ditily, and frcqiiootly 
gin nod water. First nttut-k of gout twelve yuurs ago 
in right great too ; KCooud uttuck six moutlio ufturwanls 
in both kat-vs ; iu subsequent iittiiek.'* which took plnco 
at uMCcrtnin intervals, tbu other gre»t too and both 
baiidH, wrists, kneew und elbows were affected ; there 
was much disUirtioii of both hnuds, tlio fingew were 
twisted tiiwardit the uhiu, nearly all the smaller joinb 
enlarged, itomo pro<tuciug u. grating scnsatioD on 
movement ; no external deposits iu ear or eUc- 
wherc. 

Urine jutlc, oontftining n c«D»derablo quantity of 
albumen. 

Thcpatient^unk from an attack of pleuro-pneumonia. 
On examination, it was found that the metatarao-phfu 
langeal articulatioDH of both great toes were anohyloeed, 
the ligaments around the joints infiltrated with urate 
of soda, and on forcibly eeparatiog the bones whieh 
were united by bony anchylosis, a considerable quantity 
of deposit was found at tbe original site of tlie joint, 
and in the penosteuni arauud the bono. The Bret 
phalangeal joint of the right great toe exhibited only 
a few spcclu of deposit; on making a seclion of the 
metftcarpol bone about one third of an inch Irom ila 
extremity, it vxis found infiltrated with chalky mate- 
rial. The synovial fluid of the loft knee-joint vaa 
transparent and had a vrell-mnrkcd acid ro-actioo ; the 
urticulnting surfneos were covered with a white layer 




CHBOSIC OOUT WITH CaAUC-STOSES. 



ISS 



«D(1 (ho B\-iiovial membrane finely sprinJdod ; eevcnd 
of tlu) otli^r joints were Niiiiitarly oHectciL 

Both ktdoe3r8 were smnll, the right weighed two 
and a holt, the left three ounces and a quarter. 

The capsules were very adherent, tlie surface very 
praDular, the cortical subetaQce muoh wasted, the 
pjramids reaching nearly to the surface, and numeraus 
whitu etreakii were observed in the dircctign of the 
py null id)). 

There was some enlargement and fatty disoaiiO of 
the heart. 

Case 6. — T. B., a man aged oO, not known to 
inherit gout. The itrat attack waa 32 years ago, and 
be has had numerous and severe ones einco ; for the 
lut four mouths has suffered mudi from oxlema of 
&9 logs and acfotum ; urbe scanty and high coloured 
at times, ocoanonally very pale. 

Augvt, 1840, has had no ncute attack of gout for 
eight moutlis, at present both hands much crippled, 
nany joiotA ouchylosed, some are eurved backwards, 
others ore flexed. Ou nearly all the phalanges there 
we oonndemble depasitn of urate of soda, some toft, 
etben hard. 

Both graat toea anchylosed at metaoarpo-phalangeol 
utioulatioD, left Loe at second joint aba. A few 
■maU deposits on ears. ITriae contains a very large 
qoantity of albumen. 

Hio patient died with symptoms of general aua* 



The only joints opened wore the left knee-joint, and 





^ 



MOBBin ANATOm' OP (lODT. 



the middle joint of the right index finger. The lower 
end of the femur, the end of the tibia, and nLio the 
patella vrcre covered with urate dopc«it, and the 
synovial mGmbrauo and liguincntA around tlie joint 
sprinkled over ns if dustod with a bruiOi. The middle 
joint of the right index finger contained about one 
drachm and a half of niortar-Iike matter. ^Vhe^e there 
was no deposit of urat*^' the curtilage was destroyed, and 
the bone in some places quite dcnudi^d. On m a ki ng 
a transverse section over the dunium of the first pha- 
lanx of the same finger, the tendon wna seen firmly 
imbedded in UTiit« of srxlii. 

Tim Icfl kidney weighed four and a half ounce.*, the 
surface was very granular and presented numerous cysts 
containing a glairy Suid : on section the oortio^ and 
interp>Tamidalsiib8t«ncowas found deficient inquantity 
and granular in appearance ; in some places the bases of 
the pyramids were not monj than one-tweutietli of an 
inch &om the toirfoce. In the pjTamidt^ there was a 
deposit of urate of soda, producing a streaky appear* 
anoe when section was mode in the direction of the 
pyramids, and a dotUnl one when cut in the other 
direction; the right kidnry was similar to the left: tho 
amount of deposit in tho pyramids was somewhat 
greater. There was a largo amount of fluid in tho 
pericardium and pleura, with cedema of tho lungs, and 
cardiac bj-pcrtroj)hy. 

I have examined several of the smaller joints of 
other subjects of inveterate gout, which exhibited upon 
thmr surfiioes evidence of deposition, and hare made 



CBBOKIC OOUT WITH CHAt.K-STONTS. 



1ST 



'Mdions in vnrious directions, vhich bavo enabled me 
to tncc tlic deep-MAtcd origin of the cholk-Iike 
matter. 

PIftto 3, tig. 2, rcprcsonb a liorizontal si-otioD of 
■ thamb, illustrating tfao nuiincr in wliich the deposits 
take place, and the canse of the stiffening of the joint 
kod miboequent anchylosis. It will be observed that 
tt oonnderable nmouiit of the clialky matter has been 
infiltrated into tlie ligamentous stntcturcs around the 
phalaogoal joinfas which alone must produce great 
crippling. 

On carefully examining the driimng, it will also be 
iMO that the articular nurfaccs of the cartilages are 
not adherent, or glued together, but that a cavity can 
bo shown to exist, the matter being apparently de- 
poBtcd on the free Kurfacci* of tlie cartibges, and not 
peoetrating their whole thickness : the same appear- 
aooe is also presented in the phalangeal joints of the 
fingen in fig: :i of the sami> pl»t«, where the disease 
is adTonecd to an extreme degree ; for hero not only 
mn tlio ligaments around tlic nmall joints aifected, but 
depodtioa has also taken place within the sheaths of 
the tendons, in the tendons themaelTes, and on the 
pi*n(iNteuni, to snch an extent as to produce complete 
rigidity of the finger, and bulging of the deposited 
natter. Many of the tissncs appear to be entirely 
oooverted into chulk-like matter, and in fig. 3 it will 
■lao be observed, that a nnnll quantity of urate of 
sods is acen witliin the i<ubslitni.-« of the bone of the 
fimt phalanx; tliis i» almost tlie only in«(anoe in which 




1S8 KORBtP ANATOMY OF OOUT. 

I have met with a deposit within the osseous tissue, 
but even here the depositiou appears to he in imino- 
diuto conneotion with the mattoT in tlio nrticulitr 
oartilogo. 

As CruToilhicr stntcd thiit smull crctticdous matMS 
Bomctimc« exist iu iIil^ substaiico of ttiu bono itrnjlf, 
quite roniov«d frum tlio «irti]ngo, I liitvc, with a 
Tiew "f testing this point, made numerous iwctions of 
bonoi* taken from different gouty sahjocts, when the 
surfaces were compk'tely iucrustcfl, but in only two 
cases was I ublo to detect the slightest traces of urate 
of soda. 

I conxidor tliis a question of imporlanoc, having a 
dOH relation to tlia piithology of tho dificase, Iwlioving 
that deposition con scarcely toko phtco in ii Tcry 
iiiscidnr tissue, or, ut uny Tat«, in one whose ciroula- 
tion at the time is active. The amount of deposit in 
the iinger (tig. 3) is so cxtenfiive that the blood- 
TCesols must have been consitlerably pressed iijMn, 
and probably tliecireulation in the part was extremdy 
defective, and the eretaceous-h)oking mass iu tlie 
metacarpal end of the bone was immediately in con- 
tact with the caitilage, which was itself completely 
inftltrated. I have chemically examined hones wlicre 
the cartilages were infiltrated, but oould never detect 
a trace of urio acid in their substanoe. 

Tiicre are on record some analyses of the bones of 
subjects of chruiiic gout, some of whom are stated to 
have had tophoeeous deposits about the joints; one 
was mode by Marchand of tlie upper part of the 




ALTEWATION IN THE BONES. 



Ii» 



lur, and of the radius snd ulna of a pcrsoti with 
chalk dopoHits on the koces aod elbowi). Tbti lusulfat 
of his vxamiuation were as follows : — 



ilhinhmrfiint . trvi 

lOKbODato or lim* . ... 8-34 
[Tk«*pbataof maitaMia. I '01 

i'Ftoiridw of alclDm, (Ddlmii, ehio- F 
iUb of ndlooi, and Ion > 



2-21 



Badliu (ad Ulna. 

8 -SO 

O'Sd 
4sse 

1-37 



Lchmunn ilLk) unalj'SL-d the bont^s of three persons 
with chnmic goot ; their agee varjing from 40 t« 50 
yeoin. Ho found: — 



, nMiphaU of lin* . 
iOKbcuU«(liln« 

BeloUc mIu 

tkrtUago 

IM . . . . 



I 

8G-1S 

8-<I 

1-31 

9-e3 

28-14 

1311 



t 

as -88 

SS3 

1-05 

3-03 

38 -Sd 

13-87 



• 

87-33 
SM 
1 13 
1-33 

<0'08 
e-lE 



f 

^H It will bo soeu tliat there was no uric acid in these 
^^ bones, thus eonfirmiog my own observations ; tlio 
ehief differenoe Iwtveen gouty and healthy boues 
Bffpeara to oonnst in the diuiiiisliod quantity of earthy 
matter, and tbo large augraoDtotion of the fat. 
Altboagh I hiiro not quantitjitivoly determined the 
^^ amonnt of fat in tho bones of patients wtio hare died 
^B from aggrvvated formii of gout, I am convincod that 
^H it often exists tn large quantities, but whether Ihia 
^^ ebsngo i» related cssentiaUy to this disease, or ia 
merely dependent on imperfect nutrition, rcqutroa 
fuitbor obscrrations to dotormino ; it seems that other 




190 



MOEBID ANATOMY Of GOl"T. 



L. 



tissues bosideH the booea am apt in those coses to 
become th<! seat of fut^' degeneration. 

Ono point in connection witli the mode in which 
deposits tiiko pliico. pnintud out by Dr. W. Iludd, and 
vhich ha.t a conoid cnilile bearing upon the pathology 
of gout, or at least of its local manifestations, is the 
&ct that urate of soda avoids the contiguity' of blood- 
vasseU. Dr. Budd states that in the Urger cartilages, 
auch as those of the knee-joint, immediately under 
the synovial membrane, and at the point where this 
membrane becomes attached to the border of the 
cartilage, there is a rich network of blood-vcss*^ ; 
from thLs a series of straight vessels arise, whioh piu« 
to a certain distance over thn free surface of the 
cartilage, forming loops, which ollen present con- 
siderable dilatations; wherever these vessels extend, 
the gouty matter is either very scanty or altogether 
absent. A margin of free cartilage surrounds tlieia 
on all sides, so tbat the deposit eeema, so to speak, to 
recede before the blood-vessel. Tliis is clearly shown 
in Plato 3, fig. 1, a, where tlie mode in which the 
deposit has taken place on the surface of condyles of 
the femur is depicted. 

All challc- stones probably have their origin in 
fibrous or cjirtilaginous structurtw, and are never 
primarily connected with highly vascular ti.<;sU4?«, 
•Ithough by increase of growth and the pressure thus 
induced, they may subsequently appear oa the sai£aoQ 
of the body; tliey are first observed externally in 
parts of the body where these structures approaoh 



CASES WITH DEPOSITS OS SAItS OSLY. 



ISI 



BMroft Uie Rur&ce ; as, for example, in the efin, on 
tba palmar iorfucos of tite tips of the Bogore, and hi 
other like situatiuns ; it will be Bcen by reference to 
the dmwing in Plato 3, fig. S, how renulUy deposition 
in Hush pnrta become viable. 

The aomo romarlu ospmully apply to the white 
■pocks 80 frequently seen on the car, and which ore 
equally connected with 6hr»>cartilagiiiuus tissue. 



n. — BjtamiiMtion o/tulfjeetB of Gout, mffi no appre- 
eiabU ttf/ormily, and no vitibU dtpoeiU of chaU-itonee, 
ntrpt one or more tpKkt ott the carlHage of tlif Ear. 

Cask 6. — ^The subject of the sixtli case whs a man 
about 50 years of ag«, with whom I woh uoacquaintcd ; 
be was tall and strongly made, aud had diod of some 
teste disease. There wore no appearances of deformity 
of the joiat«, the moremeuts of which seemed (o be 
performed with tolerable ease, and with the cxocption 
of three small nodulefl of urate of soda, upon the edge 
and fold of the helix of the right ear, no other deposits 
weie visible externally. 

The ear being more closely examined, the nodules 
were ohscr^'cd to bo attach cd to the fibro-cnrtiliLge, 
bulging outwanU, and Kopurnling tlio integumcuts ; it 
was exceedingly difficult to detach thum from the 
eartiiUgc, u they appeared to penetrate into the very 
•abtrtanoe of that tissue. Under the micrcwoope tlio 
wliito matter exhibited the cjystaUiofl appearaooo 
bofiifv alloded to (Plate b, %. 3), and consisted of 



]93 MORBTD ANATOMT OF GODT. 

urate of soda, united witli tlio olcmoots of the stnic- 
tare in wbioh it was imbedded. 

Eacli kidD^y was amall, undor Hiree onnoes oratT- 
dupai)^, and much coiitracti>d in »ze ; on seotion, Uie 
cortical mattf^r ytas found to be very deficient, and 
mauy white streaks of urate of soda were seen in tlie 
tubules of the pyramids : appearances wHcli will be 
more fiiUy described further on. 

As there was so complete an absence of deformity, 
aad merely the presence of a few nodules upon the 
ears, it was « matter of considerable intercft to ascer- 
t&in the condition of tho joints, in order to diitcoror 
whether deposits of urate of soda toko place upon tlie 
ligaments and cartilages of the articulations, when 
external appearances would not indicate their presence. 

The left knee was first examined ; there were small 
patches of deposit upon tlie surface, and in the sub- 
stance of tho liptmentum patcllie, as likewise in all 
the otlier tendinous structures of the joint; in the 
farmer these spots were seen on the superficial layer, 
extending through to the surface of the bone; the 
patella itself was fjuito free from this matter, although 
sought for by making sections of the bone in varioiu 
directions ; the cartilage on tlio Kurfaco of the patellft, 
which is turned inwards and performs part of tho nrti* 
culation, was of considerable thickness, and 8]irinkled 
on its surface and throughout its substance *nth Braall 
white points, some of tho spots in the interior not 
bding connected with those on tho surface. The arti- 
cular surface of the femur was marked on both condyles 



I 



J 



Ci5E8 WITH DF.POSITS OS EAltS ON'LV. 



I»3 



»iUi s Email amount of plastery dciHicit, appnrently 
Bmeared in xtreaka over the surface of tlio cartiln^os, 
u ebovD in woodcnt, fig. IS. Tho tcodons at thoir 




^ 



Fit 14." 



pnmt of insertion into tlie condyles of the femur were 
abo incnutcd, especially on tbo surfaco corre^pnnding 
to the snuiil indcotntions in tho condyle of tho bone ; 
tho semilunar cnrtilagcfl were freely sprinklod ; tho 
■ntODOr and posterior cnieial ligamouts wore whitened 

V\f(. 15 rvpmsoti Um «ail of Iba fcDior. ibaviDj tha doiuiitiiiii of 
uf MtiU ik lUMk* mpM Uh aurtkcc at tha wudfliiL Ho «lalk- 
r'uMt tx%tni»i\f, »utpt two at tlirta anuUI ipoU un tbc 
lailll^i "^ 




IH 



MORBID ANATOMV OP OOITT. 



externally, and on section, pre.«eotcd in thoir interior 
largo spots of thU dnpoMt. The artiouliu surfaoo of 
the tibia was streaked in a similar manner to thnt of 
Uie femur, but le«> extendi vely ; some patches oLso 
existed between tibia and tibula. 

Tbe right knee was affected in Uie same way as the 

left 

Tbe great toe joint was found to be cxten>iively 
diseased, tbe articulating cartilages being completely 
covered, as also the surrounding ligaments, forming 
in &ct a complete solid caxe. 

In tho upper extremities the foUowing cliangoe wore 
obsonred. 

Tbo anterior and posterior ligaments of the wrist 
joint wlitoh WH:^ examined wore vprinlded with a while 
deposit; a HmuUnuduIar deposit cxiiitcd on the external 
surface of tho 8tyloid p^)cc»s of tbe ulna ; the articular 
cortil^e Lotwcon tho radius and ulna was covered with 
white urate dejxisit on both surfaces, so also were tho 
articular curtikgea corrfsponding to the wrist juint both 
on tho carpal and radio-nlnar portions; over tJicso 
surfaces it existed in very much larger quantities 
than in the knoo joint*. Tho fingers were variously 
affected; in some the sheaths of tho tendon:? wcro 
tho seat of the dopoat, the tendons tbemselves 
being completely free ; in others, as the index Rngers, 
one joint had the articular cartilage and tendon frw, 
another the surface healthy but the tendon with n 
^■ery alight deposit on ita surface ; upon the whole, the 
lendon and ligaments, cspccinlly thiao around the 



J 



CASES WITH DEPOSITS ON EAKS ONLY. 



IBS 



joints and at the poiiifs of insertion into the heads of 
the pbaJan^ios, were mrire gonerally affected tlion tlio 
■rtumlar cartilages themselves. 

Tbe UfjamcDte connecting the curpul bones to one 
another aad also to tlio rnvtacarpus, and likewise the 
carpal ends of tho metacaqial bones, cepccially on 
ttiab doml coifiuwe, appcnrod tn bo onu masa of 
<&alk-Iiko ooDCratiOQ. 

CorpoB. — All tbc articular surfiiccs of the cuneifonn, 
wmtluiuir, and waphoid bones were covered witli a 
layer of white matter, which penetrated and inorustcd 
tho lij{ament« uniting these boace ; tbc lignmeut eon- 
Dcding Oil* Homilimur with tho sciiphoid was ono mofa 
<if thin matter ; tho cnrtila^ on the HurTucO of the 
eueiform artiL-uLulitig with ihu piiifunn bone van ab>o 
nBpKoAted. All the cartilages of tho articular surfuccji 
uf the unciform, oa magnom, trupezlutn, and trapezoid, 
ud tlio correspondiog sorfaoes of the first row of 
Mrpol U>neii were moro or loss covered, those of the 
aoctttinn and q6 magnum particularly so. The artiou- 
Uting aur^aoea of the scound row of carpitl bones with 
tbe metacarpal were etill more uniformly and thickly 
conircd, likewise tho carpal surface* of the nietii- 
flaipal. The sheaths of tho flctor tendons, aL«> the 
teudons tlicinselres, were ftupcrfidully Jnomsted, and, 
in plaoco, tho plastcr-likc matter extended into tbe 
nubttanoe of tbo tendou. 

Tho foUom-ing wore tlie apiHjarancw seen in di«- 
wvting ono of tlio lingers of this Mibjcct, in which 
Um dbeose Had nut made gnyat ravages, aa some of 




IW 



MORBID ANATOMY OF GOUT. 



L. 



tiio cartilages wore unaffected and othors very partially 
injorod. 

The corlilsge of tlie mL^tiictirpo-phulaii^nl joint 
appeared quite h(>!ilthy, but at the paint of attach- 
mont of thf lateral ligaments, a small amount of tJie 
Thite deposit was obscnred on each side. 

The Kurfocu of the lirst phalanj^i^al joint vaa par< 
tifllly covered with a thiu layer, but much healthy 
cartalago was visible, nnd cholk-lilio deposit existed 
in considerable amount at tho point of uttaohmout 
of the lateral ligaments with tho bono, llic same 
phenomenon was bccd in tlio second phalangeal 
joint; the tendons in tho finger wore found hoolthy, 
but many spots of matter wore seeu upon tho shcatba 

Several joints in this subjoot wore perfectly healthy, 
for example, the hips and ohouldcr^, and tho left 
olbow ; but the right elbow joint showed cousiderubls 
incrustation of the cartilages of the humcnu, ulna and 
radiuti. 

In most of the aifeoted joints there was some thick 
white sjTiorial fluid, which when put under the gUts 
exhibited a crystalline appearance from the contained 
urate of soda. (Plate 5, fig. 3.) 

Case 7. — In 1858 I had an opportunity of m 
an examination of the body of a gou^ man, who did 
not precient to ordinary observation any appearance 
indicating the presence of chalky deposit. 

Tho following is a short history of his case, taken 
during life. About 44 years of age, steut, uf mode- 




CASES WITH DKPOSITS OS EAIIS OKLY. 



IW 



rale height, with ttu hiTctUlary prcdjspottitioii to {^ut; 
liad alvnys lired well, and dronk rather frooly of 
porter, occasionally mixed witli gin ; hail boon enptwcd 
to Knao hardships, and was laid up with yellow fever 
m SjMio. The first fit of gout occumHl twelve years 
Won) hij! death, in the ball nf one great toe, the 
Braotul a ywir afU'r in the same locality ; since the 
httvr date he tins had several attacks in which the 
unkliw, kne<i'«, elbows, shoulders and hips, have boeu 
tSoebed ; Im death w«8 very imddon and depondttd on 
canltao diaeaoe ; the heart after dcutli was found to 
wtagfa nearly fourteen oudoos, nod there was evidence 
uf much fatty dcgeoeratioa of its tissue. 

During life this padent was free from any stiffneAS 
w defonuity of joints, and no concretions were visible, 
MTing two or three very minute points on the helix 
of tlio left car, none of which were so largo as tlie 
head of the smallest pin ; in fact, so small were they, 
llist ooly a ma«t minute and special search would 
have enabled any one to discover their existence. 

ilfae poet tnoilem iiui])ectiou gave the following results 

rin referenoo to the joints. 

The sorfaces of the bones in the mctatareo-phalan- 
geal joint of both great toctt were found completely 
ooveml as if with white paint ; there waa also some 
radnoNii of tlie synnviul membrane. The right knee- 
joint, which had been recently inflamed, exhibited mucli 
Topcularity both of the syuorial tnombrano and fringea. 
The sj-uorial fluid had a distinct acid reaction, and 
WW speckled here and tlioro witli white points. 




ttt 



MOKBNI ASaToHV OK (lOUT. 



The out«r condyle of the femur wus streaked witl 
wliitc piitelies, till? inner also, but in a sumcwtiitt tcaS^ 
degree ; that portion of thp surfuco of the condyles in 
OODtftot with the Hj'no^'ial fringes was frue. The arti-^ 
culor surface of the piitclla van irregularly .s[K>tte(L 
Tlie hciid of tlie tibin wus ;<imilnr]y »treitked to tlie 
fcinur, and the surface corresiHiiiding to the outer 
condyle had more whtt*^ df|>oait than the rest. The 
fibro-cartilages were found ntrnngly infiltrated, and 
spots of urate of aoda were viAihle upon the crucial 
and other ligaments. Tlie synovial membrane through- 
out tlie whole joint was finely sprinkled with minute 
white gianulee, the nature and structure of which 
will be described furtlier on. 

The left kidney wa-t notehed and contracted, and 
weighed two ounces and a quarter, the removal of the 
capsule caused some injury to' the cortical portion, 
which was distinctly wasted. At the mainilla of each 
p}Taniid white points were obsen'ed, and streaks of 
the while mutter seen in the [lyraniidol portion. 

The right kidnoy weighed thrcu ounoee and a 
quarter, and exhibited tlie i^ianio nppciu-auccs as the 
left. The heart was onlargod, somo atheruinatoas 
deposits were sei^n on the aortio and nutral ralvce, 
and much fat in its muscular fibres- 



Cake 8. — In 1859 I made the autopsy of a man 
fl7 years of age, who died from the effects of a severe 
accident. IIo had suffered previously from about 
twelrc attacks of gout ; the early Jits were chiefly 




CASES WITH DEPOSITS OS EARS ONLY. 



190 



I 



confined to the gnat toes, but the Eattor hnd impli- 
oUed tlic knoo*, vmts, and handa. With the cx- 
eeptian of u emf;Ic speck of urate of soda about the 
riac of a lar;ge pin's head, situated uj>on the lielix of 
the rij^ht car, no cxtt'nml deposits wero visiMe, and 
there was an abwnoe of any marked stifiacss or 
deformity'. An examination vas made of the right 
hand, nrhich biul loon Bcriuu«ly injured by the acci- 
dent, and amputated during life, bI«o of buth grout 
toes and kneei^ and WTcral other articulations. In 
the metatarKHphalangcal joint of each groat t^ii, tho 
eartilogm wore completely infiUrat<!d with urata of 
stidii, tho surface!) of tho Ncsanioid bones and liga- 
tnmts exhibiting an appearance rescmbb'ng Fij;. 16, 
but more strongly marked ; many of tbc other joints 
iif llif fwt wore slightly affected ; the kncca wcro 
rtnnked with tlio white matter to about the samo 
degree as tn Fig. 15. Ifcarly all tbo aurfiices of tho 
cupol and metacarpal bones, as abu thoso of some of 
tfav phalangeal joinu, were likewise iucnistod. 

Tti<' kidneys wero congested and granular, each 
wtnghing neaHy nx ogiices avoirdup<iis, and, on care- 
Ad oxomination, white piuntA and rtroak^ of urate of 
•oda wore observed at the ends of tlte pjTamids, and 
in tfao direction of Uio tubuli. The urine was strongly 
Bllnuiiiiiou&. Tlic deposits in the cortilagcfi, ligaments, 
iryiioi-ia] membrance, and kidneys on mici'oscopical 
cxamiuadon exhibited a crj'stalline appoaranoi. 

3. Examination o/aubjeeit of ffout, in uhOM i*o tnet 




wo 



MOltllin ANATOHY OF «OUT. 



I 



^ thalhj maitKr teas extemallg vmbU, imd \n Ofw i 
nght attacks only of the ductise had accurnil. 

Cask 0. — J. S., a mule subject, about 52 ycats of 
agti, witli whoec prev-ious history I am unacquainted. | 
Tliu body prospnted no defonnity and tbero was no 
absence of rigidity of joints, except of the nictatur8(h> 
phalangeal articulation of the right great too; not I 
the slightest appearance of chalky deposit ovm on tho 
cars was visible, although cnrefidly Bought for. Tho 
joiiita of the upiKr extremities were found oii csami> 
iiatioQ to he healthy, oven the smaller articulationa of 
the carpufi, metacarpus, and phalimgo« ; tho same was i 
the CORO ^"itb Uio hip joints, but in the knees tlio ' 
ai'ticular cartilages of the femur, tibia, and patella 
vere freely inorusted with urate of soda, as also 
almost all tlie bone^i of the tarsus and mel-itarsUH, and 
some of the phalangeal articulations. The ball of 
the right great toe was anchylosed by the largo 
amount of deposit in the surrounding bgaments, and 
a mass of considerable si/^e was found to penetrato 
into the substance of tlie first phalanx. The astra- 
galus, OS calcis, tibia, and femur exhibited no appear* 
anoo of this matter in thetr structure, but tho tissue 
was soft from fetty degeneration, 

Tho synonal fluid appeared healthy, no crystals 
wore risible in it, but the membrane of the knec> 
joints showed a fine sprinkling of whito points. 
Some of tho toes were carefully examined, in order to 
UKVrtEiiu tbo exact point where de]K)sition Brst takes 
place in the joints ; in no cuso was it obscn'cd in the 



CASES WITH NO EXTKRN.U, DEPOSITS, 



501 



lijipLinciiU wbere tlir articular Rurfuoo was not aUii 
iiujilioiUxl. The kiiincyfl were fonall and KlirivdIe<I; 
eocb weighed three ouiiocs avuirdupoin, and tho 
ranoTol of tlio capsule caused injury to the airtictd 
portioD, which bad booome n-a^Uid. At the upt-x iif 
<*di eonc white points were observed, mid strfJiks 
f of Iho samo mutter were seen to radiate in the dircc- 
. of the tuhuli. 



Oaib 10. — I am indebted to my friend Mr. J. 
for tho following observadons, which were 
ptfticulnrly valuuhlc to me, being the fu^-t made on a 
gouty eubjfcl nbo prcfieuti.-d no dofumiity or Dxtcraal 
ikpocita of chalky matter. 

J. T., a gentleman aged 75, who had Kuffercd from 
Iputy attacks for thirty years, but in whom the dii*- 
onlor hod norcr assomod a chronic form, nor induced 
■ti&on of juintti or other appreciable injury. 
At the timo I saw him be was sufToring from uh!<tinate 
diarrhoM, which caused fntul exhaustion. PenuisHioa 
waa giTcn to examuic one grc-Jit toe, and the meta- 
tBTHo-phalangcal joint was found much diwoscd, epot* 
of chalky matter being seen on the external .turfnoo 
of the ligaments and in tho groove of the peronous 
\oagaa mn^le ; when the joint was opt<ncd, the rounded 
bead of the metatarsal bone, and tho cup-like ex- 
tremity of tho phalanx, nt-re discovered to bo mucli 
tQcrunti_>d, lu alno tho )M.<i>anioid bones. The 8urfu<x^ of 
the metatarsal bone, nrliculating with the inleniol 
duunibrm, was houlthy, us also tho pulley-like end of 




SnS MOHBID ANATOMY OK OCIUT. 

the first phalanx. Tho synovial fluid wna pomewlmt 
thick, nlkaliDC in ro-nction, and tho sjTio\-iol mem- 
brane studded ft-ith niiiiutti wliito spcdu of urate of 
soda. 

Case 1 1. — W. J., n goDtlomon, «g«l 49, a surgeon 
hy profcsdun, not inheriting gout, l>ut who lind cvi> 
dcntly acquired the di»uti$o by frot^ liring. The first 
fit ucourrcd uhnut Uiirtinn ycai-s Iii'fore his death, 
and yras confined to tho ball of ono great toe ; in tlio 
second attack one of hiR knees was aEfcvted ns well as 
tlio groiit toe ; he had Huffcred allogetlirr from eight 
attacks, but had not had any during the last eighteca 
laonllis ; onco only did the disease exti'nd to tho 
upjicr oxtrcmitii.^, and tlien a Mngle joint of ono of | 
the fingers hecaine implicated. About 9ix months 
before hifl death he bognn to suffer from symptoms of 
hepatic diseaAO and afterwards from ascites, for wbioh 
hitter ho was tapped. llb< death resulted from tho- 
diarrhcca and cxliaustiun which followed tho operation. 

Buring life he wa* not troubled with stifihoss or 
deformity of any joint, and not the slightest a[q>Mr- ' 
ooee of urate deposit was seen either upon the ears or 
elsewhere ; in fact he did not consider himself a very 
gouty subject. No trace of albumen was present ia 
tho uriue. 

On post mortem examination, the lirer was found 
amtracted, the capsule thickened, and the surface of 
the organ somewhat uneven. On section, the struc* 
turc was seen to he cwanscly granular. There was 



CASKS WITH SO EXTERNAL DBP08IT8. 



303 



•omo bvportrophy of the left ventricle of tho heart, 
uul aUicmioatous deposits on tlio iiortic semi-lunar 

Kmrnuut/uMi of joinh. — In the left grciit too tho 
liMd of th« metatarsal bono was seen spiinklcd with 
depodta of urate of aoda, as was also tho cup-slmpHl 
■nd of the first phatuiix ; Vfhit* putohi-n wore likowisu 
on the articulating surfaces of the sesamoid 
booea, and the ligament had a few spate upon its 
tDternal surface. Hoee ap|>cnrance« are depicted in 
fig. 16. 




Kg, tC* 

He ball of the right great toe iras similarly affected, 
ukd b about the same degree. The synovial fluid in 



* Tic. 14 K fc if U ibo Rppoinnee of tb> artimUlini luifiuM vt 
(^ kooM of A* Ull <4 Ihc Itft ETCkt bx it W. J., in obam im\j ■>«1>I 
■ll>tll« qt t*«l k*^ "**'' OMuctkI ; na Inoi of dcpKiU mu Mon 
— *t— '"f. a^ DO apix^'abla tlilTDSM ot Ibo joloM or doTutBitj 




aoi MORBID ASATOMY OP GOUT. 

both jolais was distinctly alkaline in rc-nctios and 
uurmiil ill apjienntnce. 

Tlu' hcad» of Uie fL-inur and tibia and llio orticula* 
ting sarfiuje of the piitclla of bntb knees were pretty 
fivcJy 8prinkle<l witli white patches, and points of the 
same oould bo seen upon the synovial membrane 
throughout the joints. 

Tho kidnoj's exhibited tho p<?cul!ar phonompna so 
commonly socn in this disciiae, although, I bolicvc. 
novor before aecertained to he present in subject* who 
bad only suffLTL-d from a few attacks of acute gout, 

Oasb 12. — Ifiiy, 1859. A man 37 years of age, a 
butcher by trade and not iuheritin;; gout, but had 
Hulfercd from it fur ten years first in the gnwt toes 
Slid afterwardit in tho ankles, knees, and viista ; cf 
late as many a^ threo or four attaelu occurred annn* 
ally ; for some time he had suffered from much diffi* 
culty of breathing, and the urine was albuminous; hv^ 
died from poritonitis. For the last six months he hod 
uot been troubled with gout. 

Not the slightest trace of external deposits of urate 
of soda WHS obsen-otl, not even a spock on the cars, 
nor was Utere any deformity or slilfnes* of the joint* 
On u]>cning Uie metntarso-pbaliuigeal joints of each 
great toe, the cartilagi^s of tbo boue^ including the 
sesamoid, were found much cucniNt'Od with a white 
deposit of urate of soda, some white matter also was 
seeo in tho ligamentou.i structures. The phalangeal 
joints were perfectly free from the disease. 



1 



i 



CASES WITH KO ErTKBS.U. DEPOSITS, 



£05 



I 



b 



. Tury slight stivnkiiig was observed in thv right 
Imcv-joint ai)d on the condylos of the fciniir mid siir- 
fiuscof tlio tihia, btit none in the right (^lbtJn■; thoothirr 
■rticnlationg were not cxftminc<l. 

Tlie Ivft kidney was short and thick, cupsulo very 
fipoquo nnd odheront, and, on attempting to remov« it, 
tlio sur&co of tlio cortical substance vas much injured, 
md exhibited o granalar appearance. AVeight, five 
maoea avoirdupois. 

The right kidney similar in appearance to tlio left, 
bat with a largo oyst on tta surface, extending into 
the cortit^al atnicture. At the end of the pjTamida of 
both kidneya white points were observed, and many 
KTWik^ along the course of tho tubuli uriniferi ; the 
points and streaks exhibited a cr^'slalliiio structure 
under the micnwiGopo and wcn^ coni])08ed of urate of 
eoda. 

Cask 13.— Mgusl. I8A9. J. S., a niiin aged 50, 
who died from tJie eflccts of an accident. The circum- 
•taaoes oooDOctal with tbo cai»ei were as follows : — Ho 
WW thrown down by a cab, which caused some injury 
to tlir right knee, and a bruise of a slightor character 
ia the loft foot Oangreac occurred in the right leg, 
which made tt necessary to have rooourae to amputii- 
tun (if the thigh ; the stump became aifected in a 
smilar manner and the putieut soon died from ex- 
haustion. Prom the histor)' of the case obtainnl from 
bis wife, it appearud Uiat he hiul Ikxii subject to 
oocasional attacks of gout for the luit ten ycara, 




30S MORRID ANATOMY OF UOUT. 

affecting principally tlm great toc» und diildc*, and 
now and thon a joint of tho upper cxtrcinitii.'s. He 
bfld also experienced ono slight attwik in tUo IcA 
knee. 

The patholopcal iij)i)Ctiranco» discoviypcd nftcr death, 
as far as tho guuty ulfcctiuu wtu conGcnied, were u 
follows : 

Tho ciLftilngcs on tho htHtd of tho mctafaisil bone 
and first ])hiiliiiix of the right gruut toe wero eoonisfad 
»-ith iinilo of swill orcr more tluin half the extent of 
their siirfnces, and some deposit was present on tho 
BCBunoid bones ; i>j>pcks of the same matter were like- 
wise seen on the inner snrfiieas of the lig!unenl«. Tho 
left grcftt tuo was similarly affected, but in a slighter 
degree, and the niiklu hunesof the sumo side exhibited 
white pntdies of tho e^lt ; no traee of deposit wa» 
found in the right knee-joint. As it lifid lif-n pro- 
viouiily ascertained that the patient had experienced 
ono niiyhl nltack of gout in the left knee, it heeamv u 
mutter of cxtrcuic ititi.-ro:4 to observe the condition of 
this joint, and uAcertuin whether any morbid appcur- 
ancce remained from tliis attack, which hud occum-d 
some years previously. No deposit was ob!<or%"ed on 
the surfaces of the tibia orticuhitiiig with the condyles 
of the femur, tlic inner condyle of the latti'jr bone was 
likewise fixH^!, but on tlio anti^ior portion of the outer 
condyle a small ])atch was iteeii, not exoeeding a sixtk 
of an incli in breadth, and about half uii inch lu hugth, 
the deposit gradually becoming loss dense from hc-fore 
hackvi-ordj ; in tho notch between tho condyles a veiy 



* 



CASES vnrn no exteusal depostts. 



Si>7 



small spot was b'kcwise seen ; a speck sbout the size 
of a pepporcora was found near the tuberosity on the 
oati>r Bidi- of tlie external I'onclylc, coniiock-d with tho 
lattfml ItgamcDts. A eonsidiTubk- nmouiit of aralo of 
•odft was Men on the articulikting surfuco of the piitvllii, 
■Inwrt entirely oonlinod to tlie outer half; a portion 
of thU was very sujicrfioiitl, but some deep seated in 
the cartilage, approitcliiiig cl(»3o to the osaeous tissue. 




Fi|. 17." 
In the li^mentous stmcturee upon Ihc outer mrfuce 






ta MOBBID ANATOMY OF OODT. 

of tho patella, minuto s]>ocks of tho samo salt wcro 
>-iaiblo; tliest) appearances are delineated iu fig. 17. 
Tht! only other morbid phenomenon pi'eapntcd by tho 
joint were a few scattered and verj- small white poiata 
upon the under surface of the internal semi-lunar car- 
tilage, but too small to bo oshibitod in a woodcut ; tlie 
crucial ligaments were quite free. 

Both kidnoj's were small and pale ; tho right 
weighed three ounces, the left two ounces and three- 
ijuoi'ters. On removing the capsules, the surface pre- 
sented a granular appearance, and on section, Uio 
cortical substance was found to he wasted, A deposit 
of crj-stallinu urate of soda in the form of spots and 
streaks was soon at the mamilla of each pyramid, 
and in tlic direction of the tubuli. The urine was not 
examined. 

Oasi 14. — 0. H., a man -DO years of nge, inheriting 
goat both from father uiid iiiotlior's side ; hii* habitx 
had been temperate, ho bad an attack of gout four or 
five years ago in the ball of great toe, i^iid again six 
monthf kftiTwnrds, but has never hud more than 
four or five attacks. 

Tliia patient had suffered for the last six months 
from dropsy consequent on cardiac disease, from tho 
c&ecta of whicli he gradually died. 

On section there was found much deposit of orate nf 
sods in the balls of both great toes, no other joints 
were afflicted. 

Them was much disease of aortic and mitral 



1 



J 



<-*ASEIN' WHICH ASlSr.LEJOINTWAS AKFKCTKD. 209 

vdvM, with coiisidfralilfi cardiac hypertrophy; the 
IddDcjB appoarwl healthy. 

4- EitamiMiioa of a «tilff'eet in irhieh oiihj tJw- ball of 
the riijht great toe had hten ^ffecied uith gouty inflam- 
mation. 

C*.iK 15. — TL. R., a man agvd 60, with no knon-n 
bere<tit4U7 prnllspositioQ to gout ; during the Iiutt tuii 
years ho had ttuffiirod much from palpitation and difli- 
cnlty of brpttthing, Kyniptom.'^ clepoudinf; on the pre- 
of hj-pi'rtmphy aud valvular di.'<ca.'«c i)f the 
; be had also been mudi troubled \t'ith cough ; 
be had a]wa>-8 MwA well, and had drunk fredy of malt 
liquuni. Threv yearn and a half bi-fori) his death a 
diltiaot fit of gout uecurrod in Itiu bull of the right 
grtat toe, uf modunito screrity ; mid a year anorwiirdi) 
s woond fit in exactly the $ainc situation ; tn Dcither 
•ttodc wore other joints implicated, from the time 
of the socond. attack uiitil bis death he had not the 
slightest retiim of gout. No albumen was present in 
the orine. A post-mortem oxaminatiim revealed con- 
ndenblo oanlinc di:!caso, tlio heart woighini;; twont)'- 
ox OBBoee »voirdujM>in ; the walk of tho loft ventricle 
wre modi thickened and thv aortic valves covered 
with excreooenocst and altugvthcr incfSdent; the 
fcidoeys, weiphing rax and seven ounces n«pcctivdy, 
wtT«f apparently healthy, with the oxocptiun of a large 
cjvt in the rif;bt. llie motatorso-phalangeal articala- 
ttOD or ball of the right great too, the only joint orer 
inSauMl, exhibited the following appearanoM when 




«10 



M0BB1U ANATi>l[V OK OOltT. 



(^Koed: — A moderate amount of sj-novial fluid vas 
preeent, beatthy in np^icaraiicc, iind distinctly alkidine 
in ro-ncHon. A lurgc wliitu putch vans tfocn on the 
hcud of the motiitarsiil bone, occupying nbout ono-tt-nth 
of tlu- wlmlo Riirfucc, aiid viiim odrefully cxainiiiod 
fountt to con!ti.it of several minnte patdics uggrcgatod 
togetlipr ; on the nnrfiioe of the cup-likn end of the 




Vis. IS* 

phalangeal bonp more of this white matter was ob- 
Borved, occupying pcrliups as much ns one-fourth nf 
the cavity ; tlic deposit wan not dcn!>c, and did 

* nt. 18 <1). Dnini from the W1 at the right gnitl Ut of R. K.. 
■ )«tl«Dt irba nnljr «lp«rioiie«(I Ivo iiUgtit BttAclu ol S°o(> ^"'^ ""o- 
fitud lo thi joint in qostioD. 

Fig. 13 ^Sl rcprctcali Ihi appMnsM of Uis tai of phalacfMJ ban* 
of the cuTMLiuii-luig JoiDt o( tb« left sreat to% in vhich so tnm of 



J 



CASE OF A SEJtOLE ATTACK OP GODT. 



Ill 



Dot appear to cauoo aiiy elevatbu of tho fiurface. 
The nrticuluting surfaces of tlic sasmoid bona; 
wen? free. Tlif«o ^appearances are represented in 

Bendes those dt^pwitis it will bo obaerved that there 
was a v«ry distJiint sprinkliiig uf tlio Hamo substance 
upiiti the inner eiurfiicv of thu Iti^muDt^. 

The oorta^nding joint at the loft grunt too was 
healthy^ a^ also the phalangeal joints uf both font, uod 
•ereral other joiots of the body whidi wore oxmiiiiicd. 
F^. 18 (2), exhibits the appearance <it' the cup end 
of the firet phulunx of tho healthy toe. The deposit 
thown in tho drawing was uxamincd mit-ruwupically 
■nd rJu-inifi«ily, and found tii I>o i<ieiitical both in 
form and eompositioD with that constantly found in 
this diseon, and which will bo fully dfe-tcribcd in the 
next chuplfrr. 



6. EgamiHatiOH «^ a nibf'eet in tchom hut a nnffle 
attnek <^ (/on/ had orctiirtd, and thai liiiiffH j/ean 
Uforttifalh. 

OAfiK m. — B. Il.,an ostler and coachman, aged 45, 
had always tived woll and novcr talcen more than 
fear or Grc pints of porter daily ; i^d not inherit guut 
from cither piirvuti<. 

About lbtrt<'cn yearn ago had an attack of gout in 

the right grcnt too, whi<!h lasted for about a fortnight 

and was iwrvere ; with this exception he had always 

enjoyed good health, and baa never had a return uf 

the ({out. 

r t 



US 



MOUBIl) ANATOMV OK OOUT. 



Ho died from cardiac disease fta-ompanied witli 
luemoptysiH and pulmonnrj' apoplexy. 

Tlio iiiotatarso-p)ia1ang(.-&l juiyt of the Hght grout 
toe vas fuuiid miicb oncrusU'd with wliitv piUchea uf 
urate of tmdii, thi; cups of Hid plialiuix Ix-ing mort! 
than three- foil rtl 18 oovcroil, thv tioail of the metatarsal 
bone less HO ; on Uip phalnngciil joint of the same toe 
a few white spits wr-rp also seen : those appcanuiOM 
arc accurately dcjiioted in fig. 19. 




Pift 19.' 

The patient had only qKtkon of the gout ns afiectin^ 
tho right great toe, and he particularly remarked on 
the intensity of the pain in that part ; however, od 
opening the first joint of the loft great toe a few 
specks were seen ; and one lainutc {Kjint in the pha- 
langeal joint ; tlie appearance in the former joint is 
delineated in fig. 20. The knees contAined no trace 

* Fi(. ID. A <lr**iag Tram llw right grmi to* of B. L, • mu vbo 
bkd bat KiiDslcatUck of goat IS ;t>n befuradtatb. 




CA8B OF A SIKGLK ATTACK OF CODT. MS 

of deposit. Dor was any discovered ia any otlior joint 
iaspected. 




Kg. SO." 

The kidncyH were congested, wt-igliing G{ ounces 
each, and uo white point» or Ktioulc^ obtiervcd. 

* Pt|, 90. Tbc Dctabtnn-phaUiignBl joiiit ol l«ll gmA to*, frani 



fl4 



MORBID ANATOMY OF GOOT. 



CriAPTER VII. 



Monnm Air>TOi<r or Gout coMrniim :— DiDcnian diuwii wmam 
Ttia dtaiu KiLitTiiii m tub laft ciiimB^—rnoan or to* ik- 

tiuir or TH(iK ODUt— mcnmooMo uid mivKiott ui>«iiactkm or 
oovrr VRPoaiTS in mrriKrat nRnctnitn— ik aitTiODL*a etxn- 
i.iut— nrortiL iiiHBiuBa--TiB>ocji timo*— AnenTboai or 
SHUT TOB— oBiiiau :■ tna EWKia or oodtt humxjm : 1. 
)« Tin aimoiiio raiuit or ran utLjttiT ; 2, in tiij UUT 
Rian— Dirc4tn lit omttn BiTuitioNa. 

Fkom an investigatioQ of the phenomena brought to 
Uf^ht in the last chapter, more especially with n'gard 
to cases of gout iu which no appreciable deformity or 
rigidity of joints existed during life, some rerj' impor- 
tant deductions may be drawn ; dedudioDs which 
cannot (ail to exercise a strong influence upou our 
ricwB of the intimate nature of the disease, and which 
we shall now endeavour to explain. 

In the examination of the first class of casm^ 
namely, suhjocU of chronic gout, with extensive chalk- 
stones — the results of my observations, as far as tho 
appt^amncoH to tho naked cyo ore conccmi'd. huvo 
already heeti soffioicutly detailed : such, for uistAucc, 
as the mon.' nr Ium t-omplete incrustation of the surfaces 
of the bouos with urate of soda, the infiltration of tho 
surrouudiug ligaments, depoeitB within tho tcndoiu 



H 



DBDnCTIOKS FKOM MOKBID APPEARAKCKS SIS 



ud Uieir AlieoUu, and oocasiounlly along the feodi- 
Doas exiMmsions of the muscli^i. After a tiine, when 
the Bocrctton of urate of soda iuto the tissuos increns&s 
ocighbouiiDg puirts arc prcesod upon, atrophied, and 
almrbed, and the dcpositod mtitt«.T slowly approaches 
the surfitoe, tuouUy ui a semi-fluid form at Hist, but 
gradually becoming solid uud chalk-like from the 
■bmrptioD of its more fluid portion. Whoa tlicro is 
unly nn intcf^ument covering tlio cartiliigt;, us in the 
OMO of the helix of the car, tho deposit makes it« 
■])pcftnuioo at tJio surface eooa after iU 8ecrotion, but 
when numy other structures arc interposed, a con> 
sidermblo time elapses before this oocurs, and the 
deposited matter may undergo considerable haTdeoiiig 
from absorption. Tho only point in which my obser- 
vations differ from those of Cmreilhier has reference 
to tho ocourrenoe of the deposit within tho subtttanco 
of the bones and altogether disconnected with tho 
CRrtilage. Cruveilhier found it in tho astragalus, os 
oakis, and patella ; I hare iroqucntly sought in tliose 
situations, but liai-o norcr seen it except in direct 
eoiuectioa with the cartilage, although in some of the 
phalaogee it hud penetrated to a considoniblo depth, 
and tho ossooas tistuo Imd become much prcasod 
iip»a and atrop>iicd. 

In tho Bocond class of cases, when no apprvoiable 
uty was present during life, and no cludk- 
stones except one or two on the cartilage of tho 
imn, tlte oxaminatiun brought to light tho fiiet. I 
bdiuvo before unknowu, that extonsirc defjosits may 



Slfl 



MORBID ANATOMY OF GOUT. 



take pUcc withiu the jointo without oorrespondiDg* 
external manift'station ; it was uIgo rcudcrad probable 
that a closo rt'lution i'xi»t.s butwccii the prcionoe of tho 
deposit and the occurrence of true gouty infiammatioD ; 
for in Case 6 tho joints less commonly implicated wore 
&ec &om dcpijsit, as both liip and shouldcr-juiiitA, and 
one elbow, whorcus thu joints more froqueutly affected 
with gout were found incrusted. As the hi]<tory of 
the case was unknown, there were no means of posi- 
tively ascertaioiug which joiubi hud been influaed 
during life. 

In the third ohuw, when not a trace of external de- 
posit wua pcroopliblc, it was Ukcwisc donionstrated 
that the cartilafjes and other structures of the joiut» 
may be infiltrated with urate of soda. 

In Case 10 one great toe only was examined, and 
here the interesting fact was elicited, that the articuhir 
cartilages of tho metatarso-phalangeal joint may be 
completely incrusted, the Burrounding ligamentous 
tissues Crcely sprinkled, and stil! tho articulating sur- 
face of the metatarsal bono with the tarsus, and like- 
viae tlic phalangeal joint, remain free &om disease ; 
this I have seen in otlier instanocs, mud it oxenipUfiBS 
the great tendency of gout to select one joint in pre- 
ference to OtllOR. 

In Case 9 many joints of the lower ejrtrcmities 
were affected, but with complete freedom of the 
upper limbs and hip>juiiit« ; tJius pointing to the same 
oonolunoQs m Com 6i but in a still more marked 
degree. 



DEDUCTIONS FROM HOKBID APPEARANCES. S17 



By Cuse 11 we are enaMed to caa&rm in a remark- 
able manner tKo oonolu»ioii!i to which tlio foregoing 
oaMM point. The hLitorywuK n'ell kiKPwn; the patient 
had been a mi>dical man, und could ({ive tlio detoild 
with oucuraoy, and it wa» positively awc-rtained that 
be had experienced but eight fits of gout, and these 
had been sprvud over a period of Uiirtoen years ; once 
only wiu II finger affecU.-)], the rcmiiiDiiig attacks boing 
ooofined to the great toes, foot, and knees. la thin 
use tlie examination Ahowod an incruiitntion of alt 
tbe joints known to have been imjilicated, and tlie 
Freedom of the rcAt, and thtm proved almost to denton- 
rtration that gouty inflaniniittioD is invariably accom- 
panied with depotrition of urate of soda. 

In Case 15 this fact was proved bej'oiid all roiuoa- 
■bUi doubt, for the patient had only experienced the 
dieeue in a single joint, the ball of one great toe, and 
even in this it liad nnt been severe ; still the surfaces 
of tbe metatarsal bone and phalanx were sprinkled 
ofer in a marked degree, and a spot was Ukewieo 
obaenred on the ligament. 

Casee 13 and IC, however, eatablish the fact abso- 
Intcly. In Cn>^ 13 ertdenoe was obtiuned during life 
that tho left knee had been only oncv affcctci] with 
gaat, and llion vcr)- slightly, the right knee hariog 
boea aln'ayA quite free from the diHcane ; the post- 
mortvw examination demonstrated a slight depont in 
thfi stiuctureii of the left knee, but none tn the right. 

And, lastly, in Case 16, the result of a nugle fit 
of gout was characteristically rmTalcd. After this 



SIS 



MORBID AKATOUY OF flODT. 



evidence, how is it |K>i<»ib1c tu doubt that ffOHty injiam- 
Htatha M imarkhly attended irith the dcpoutioti iff uittte 
of soda f 

The other morbid uppcarancos scon in jointu af- 
fected with gout are companitivi^ly unimportant, 
being tsimibir to those obeorvod afttT otlier forms of 
inflammntioD, as reduces, thickening, and dryness of 
the synovial membrane, and occasionally oSused fluid ; 
but these phenomenu var>' much with the time which 
tue cla])»L-d siucv tlie communu'incnt of tho attAok. 

"Thfi eEtublishmiiit of tho fact that gouty iiiflamma* 
tion is iovariably accompanied with the dopositioi) of 
a peouliar nalt b of the highest importuicc, inasmutdi 
as it proves tho inflninmatian to have u Epmfic duu 
rocter, and to differ entirely from the various other 
morbid affections of tho joints with which it hu 
hitherto boon confounded. 

I may add here that although I havo made many 
examinations of the joints of the subjects of diRcrent 
articular diseases, in no other affliction hiive I ever 
detected this deposition on the cartilages or oLsewhere. 
It Dcver ooours in acute or chronic formn of rheumatiicm, 
nor in rheumatoid arthritis, tho disoaw commonly 
known by tho name of chri>nic rheumatic arthritis, 
altliougb alterations of a still more xerious nature are 
frequently met witli in this last affection. 

I am of opinion that not only is tho dcpontion of 
urate of soda constantly found in gouty inflanunataon, 
but that it stands in relation to it of cause rather than 
effect) that is to say, the deposition of the salt tirst 



4 



J 



MJCBOSOOnC CHARACTERS OF GOUTY DEPOSIT. S18 

tsJcoe place in Uie synovial membranct, oortilngcs, and 
Icodioous stmctoree of the joints, and by ite ))n'«oii(M3 
gives riso to inflammatoiy notion. Many ur^iiiDCDts 
might bo adduced iii support of tliis statement, wliich 
Te shall have an opportunity of more freely diwusnng 
ID a futnro ohaptcr ; I may, however, allude here ia 
tro circumstancoH strongly favouring the above view; 
Damcly, that when deposition occun; in purt^ of low 
ntolity. Ds in the fibro-cartilages of the cars, there ia 
oomporatircly littlo iuflammittion, although often suifi- 
cioiit to call forth the attention of the patient; ugain, 
wlujo iiiilnmmatiQn nins high, dcetruotion of the urate 
[at aoda to Aome extent rcsulU, as proved by the ab- 
o of urio acid iii the blister scrum of the i n fl a med 
put 



MicroKcpie and Chetttieal Charactera of Goiiiy 
\Jiq>oritain d^fferetit Stnwtiiree. — Wc have sjwken of 
' the white plaster-Uko matter on occurring upon the 
oaitilagofl, ID the tendons, and other parts, without 
pnrticaUr refDrenoe either to its minuto charactera or 
chemical compoMition ; to those points it Ls incumbent 
uptiu mt itow to diri-ct our attuntion. In the de^crip- 
tioo already given of the morbid a]>peaTanoc8> wo 
haTo seen that the chalky dopnrit haA been »umetiuics 
stated to replaoo tlio cartilage sappowd to have 
booomo abmtbod, somotiiDes to have been eprcad 
orer its surface in the form of a thin layer, the car* 
tilagc remaining intact ; both theno Ktatcmt'nts are 
enxmeous, lor as wc proceed iu our ioquiriDS wo ahull 



no 



MORBID ANATOSrr OF GOUT. 



fiiid tliut the vhlto deposit is alt^gothcr interstitiitl in 
cliiinicti-r. 

In u cummimicatiaii an Qout published m the Tranft- 
notious of the It<i\-al Kodical and Chinirgicol Sodety, 
184S, I gnvc a draning of articalar curtilage taken 
from the metatarsal bonp of a goutj- patient, whoso 
foot had been amputated by the late Mr. Liston, and 
it was there shown that the white deposit was entirely 
crystalline, cousL-sting of minute neodles of unite of 
soda, arranged in the maimer exhibited in Plate 6, 
fig- 2. 

Subsequently I exhibited a specimen at a meeting 
of the Pathological Society, pro\Tng that the deposit 
was not on the free surfuw of the curtilage, but that 
a thin orgonio layer could often bo demonstrated 
external to it. 8inco this ponod Dr. W. Budd luis 
purticulurly oxamined tho Etmcturc of ituch curtilage, 
and tbc results of hi!> investigations aro published in 
tho Mediofll and Chirurgicnl Transactions for 1855. 

If wo malcc a thin vertical sectioD of a piece of 
ooitilagc nontaining this deposit, tlmt is, a section 
cut firom the free surface in tho direction of the bono, 
we at once discover that the matter ordinarily extend* 
to a comparatively small depth into tlic mhstance, 
seldom penetrating beyond two-thinls of ita thiokueBs, 
often much l(«s, and it will also be .seen tluit tliis 
deposit presents a beautifully rrj'stalline appearance, 
as seen in Plate 5, fig. 1. The phcDomcnou can be 
well observed when we cxamino tho specimen with a 
linear magnifying power of from 100 to 300, either by 



MICROSCOPIC CHABArTEUS OP GOtlTY DEPOSIT. 331 



tnuumittcd or reflected light, and still more .tutiitfno- 
turily by the nid of iwlamed light. Dr. ItudJ, in tin- 
paper iibovL< alluded to, staXix thut the foreigii raatK'r 
takes two distinct foniu, in some idtuatious being 
'graintlar or iinioqihuus, i» others perfectly crystalline. 
1 have made some hundred ntvtioDii of csrtilflgo taken 
from many gouty subjects, and from various jointf, 
and ulthough the nuitter has at first oatasionaUy pns 
Beutod the granular form, yet further examination, 
more especially by the aid of the ])olariscope, has 
always eho«-n it to consist uf minute crystals, the 
lUnorphous uppeamuce having been iliie to the direc- 
tioD of the needlen, and not ti> any wiuit 'if enr^ulli- 
tatioa. lu the dmvring, Plate 5, 6g. l.the thin mem- 
bnuious layer external to the deposit mil be obaen-ed. 
It phenomonou which has alsa Ikvd desenbod by l)r. 
Itudd in tlie oonununicatiou before alluded to : Ur. 
Toynbee, in a paper on articular cartilage, in the 
Tyiudon Journal of Modidiic, 1850, oonaideied that 
this discover)- of the thin organic layer, argued strongly 
fur the exieti-nue of a Hynovial membrane over the 
articuluting suifaoi*. In Plate 5, fig. 3, « horizontal 
Mction of tli« cartilage in kIiowq ; the crj-Mtnls. how- 
ever, an seldom met with m> sj-mmetrieiUIy arranged. 
Tba aboTo drawing was made in IA48, from the 
cpCcsmeD given to me by Mr. Liston. 

The density of the deposit is always found to 
be greatest at the snrfaco, gradually becoming len 
as it penetrates into the etntcture. In bonc« whicli 
an ably mi>dent<dy sprinkled, the peuetiution doe« 




SB MORBID ANATOMY OP OOITP. 

□ot ofUn cxCocd ODC-tiuTt] of tho vholo tliiuknCB^I 
or itt loiut the crj'^taU btcumu so few otid lini- that 

(hey oro not viinble be- 
yotid (\m depth uolcet 
^'Ti>ntprc<'iiuti()iiNnn>adnp- 
Uii, but snmctimes ujHin 
thp md of bones which 
hure long been tlie sent 
of tho (lisciLsc, ihc entire 
thickness of the eArtiltgo 
wcms to bo ua])1irAtcd. 
1^«- ^1* Till? appearance prcseotod 

bjr a thin vertical section when seen under polarised 
light, is rcpre«-nt«d in fig. 21, the fine priHoiatio 
needlea arc obwrred to penetrate to some consider- 
able depth : nenr the suifaee the light is intrnae from 
the interlacement of iiimimerable crj-atals. ^"hen 
properly exhibited as an opaque object it is also very 
beautiful. 

In order to determine the intimate nature of the 
deposit n-ithin the cartilage, wo have only to take 
tlitn »licra of it, wa»h thimi with cold water and 
afterwards with alcohol, for the purpose of removing 
any matters readily ooluble in !<ueh ni(-tistnin, then 
digest in warm water, under 200* Falir., until the 
cartilage ha.<) become transparent; the watery itolution, 

* Fig. !1. Til" ■]ii>«nnM prnmUi bjr » vgrj thin v«rtie*] MOtioa 
ef gout; outiloKe : (hi> niiitl*!' i* tna la b* mart d«nM U tba Tim 
■nrfow, ud gmluiLll; to bvmme tbiDMr *a it {KDettatM iutu) the 
ttraetar*. Prom a tpccinien prnarsd in CuiaiU balMm. Linou 
nagnifftag po»ei 230. foUriKd l!0>t. 



CHEMICAL CUARACTERS OF OOm' DEPOSIT. «n 



^ 




■ft«r evnporatioQ uod cooling, will dqiosit beautiful 

Ittfts of cryRtala (Fiy- 22), which can be readily de- 

moQstrahKl to cotiinst of pure urate of Hoda, as a 

aoluLle alkaline aah is left, 

after inoineratiati, oonsist- 

ing of oarboDfite of soda, 

and the cfystals dissolved 

in wat«rt and treated with 

acetic acid, give rise to uric 

acid in its chamrteristic 

rhombic foniis. (Plato 6, 

Hg. 1.) If llio erystak 

be traited vith dilute "'& ^^■* 

nitiic acid on a pieco of white porocliiin, avd, when 

almost diy, held over a solution of ammonia, tbejr 

givft rwe to a brilliant purple nppcamnoe from the 

production of tnurexide. By these reaotions, as well 

u fiom the fonns in which the salt crystidlise^, it can 

be dentoostratcd, tliat the inuttcr giving the white 

optttd^ tn thi' cjirtilago (^ouMNt.* solely of urate of 

•Mia. 

When the extremity of n bone completely an^ 
thickly covered with urate of soda, Li dig(«tod in 
warm water fur some days ^'o whole of the deposit 
ta removed, and it then prvscnt-t an olmuEt healthy 
^ipenraooe, being \cH completely covered witli cnrti- 
b^. In some of my experiments I should have 



* fli. n npMKDU tliB crjtUlluBtiaa of niaU tt Md» bum %lw 
VBMj ■tlaliOD la wbieb coDljr c«rtjlk(e hail bfr* disMlod. (MU luder 



'»! 



UORRID ANATOMY Of OOUT. 



been unaUe to determine whether it had been pre- 
viously diseaaed, for the only difference which I hiivo 
oh»tervcd, ba^ been a sotnewhut tmovcti surfuoo oud a 
tnint'pftrcnt and spoTig\' apjK-nrAucv of the vutrtilagc on 
dniiig- To nscLTtttin tliis jxiint without risk of error, 
I have token tlio end of two bcitic« from the 8Aino 
individuid, and subjected them to siinilAr influttnces, 
citlier to wiitcr nt the temperature of 100° Fubr., or to 




ttie aotion of a vrealt solution of the carbonat* of somd 
alkali. Fig. 23 shows the appearance of two meta- 

* Pig. St npTV««uU thu fndt of tiro mctuarpikl bonDi, one [Denuit«d 

with unite oF n-ia, thf olhtr tnrd fnta the dapoiit lij thfl •elion 
of v*na •Tftlct, unil cihlbiUng tho otrtilago a;ipnTOilty bmttb; ia 
■tnclnrt. 




CHEMirAL CnAILU'TERS OF (lOlITY DEPOSIT. 22B 



W 
I 



^ 



bones, nno incrustod with the deposit, the other 
fim it hy Uifi long continued action of wnrni 
wntcr : the hitter ws-i, if anything, more thickly co- 
vtnd than the foniier hefnre tlie commencement of 
the cxi>erinieiil. These olwteiratinns [irovo beyond 
dnabt, that the idea of tho &uppo<4ed absorption of the 
cartilage, and the after Rujx^rpnaition of a layer of 
foreign matter, ii erroneous, and that the deposition is 
votin-ly interstitial in its nature. If thin layers of 
gautjr cartila^ are submith^ to the action of warm 
wntvr for some hours, the deposited matter will bo 
gradually diswlved until at length it in quite ri'moved, 
after which the cai-tilage will be found to Imvc tvko- 
retvd its healthy structure. By such a mode of 
prncenling, watching the specimens in the different 
iitugt<n, much light will be thmwn upon the mode in 
which the depi><iitiun has onginnlly tuken place. In 
•nmt? fl|icctinen4 I have noticed, that slU-r much of the 
onitv of "chU has been removed by the water, rhom- 
lie cry»tiilrt of uric acid have been left within the 
csorttlagv ; it in however probable, lli»t ilie twluction 
of the acid is only a poflt-mortem rB<>ct from the 
gtWeratioD of another acid by deponipnwtioii. In 
almost every case I have observed, that as the solu- 
tion of the urate of soda proceedx. the depivnt amumca 
the appeanuioe of i>niall masses of orystaU wpnrat^d 
frmti each other by clear interspaoee, and aft«r tlio 
fiullxT action of the water, 6uch masBes have often 
ap)M-*anxl to occupy the uluatton of the nttcleus celU 
ol' th4> tis<ut> (Plato H, fig. 1). 

4 



»• 



HUKBID AiTATOUY OF OOUT. 



In (l<>taiHng the poat-mortflin examinatioDB of tlio 
joinU of gouty subjccU, wo atatod tliat Uie Bj-novial 
fluid was oocaeiioiially of a thick cansifit4<nce, and more 
or leas opaque, soin£!tiTn(<H Htuddeil with little whitu 
pointf) ; when oxniiiiiio*) by the imcroscopp, it is found to 
be crystalline, pslubiting fine needlos, or prisms, usually 
aggn-gatt<d togptlier iii the form of bundltji. The 
crj-stals are soluble in warm water, the solutions )-i«1d- 
iii^ tho chnmetfrifltic- muri'xido test, and on the 
luldition of an acid, d(i>ositiiig rhombic <irjatals of 
uric acid : in short, the opaque matter within the 
s^Tiovial fluid is proved tu be urate uf soda, the sume 
Bolt that exists within tho curtiluginous structare ; in 
SomiO of tlie more chronic forms of gout, masses of 
white matter have been found ; this, however, does not J 
commotdy happen, and even in joints very confdder- 
nbly ufil-cted, the cmnties often remain free from 
deposit, althouph whito paints may be visible in tlio 
B}'noviul fluid. 

In sjwukingof the dissections of the larger articula- 
tions, imd more e*pi'cifdiy the knee-joint, very miniito 
whiti- point« have bi-en noticed ax occurring upon tho^ 
synovial mcmbruno ; if u portion of this tissue be 
removed, and placed under the microsoope with a low 
magnifying power, about 60 linear, witli the use of 
polarised light, an appearance represented in Fig. 34 
(1) is observed, showing tbo studding of the Dtcm- 
brano with small white maraes, arranged at somewhat 
vqofd distances fruui each other. When a very 
iniuat« mass is sclt'ct^'d and subjected to a higher 




flARArTF.B OF DEPOSIT IK RYNOVIA!, MRMIJKANE. SST 

power, about 220 lincnr, the crystalliiic Btnictiin* 
lieeomeci npporent, rapcdally if a little pressure bo 
osod apon the thin upper 



COTcring the mem- 
bmoe, by which means 
• globular mass beoomcti 
and the occdlrn 
orate of soda rondrred 
more crident ; this \s m- 
presentcd in Pig. 24 {2\ 
When the membrane ia 
sabmittcd to tbc long con- 





Fig. -a.' 






tinaed adiun uf wann water, the niiis<os arc grndunlly 
difisolred, and Uic tissue loft in nn iipparcntly noimiil 
atotc. 

Ligamontous iukI l]bni-cartali>giit<»a'< tisMit.-<, tvndoiio 
and tli<>ir Nhcatliji, when incrusted u'ith unite of mdn, 
it under the niiorosoopu appciuiLnccti ven- tiinilnr 
tiioso of urtJcular cartilago> although it frequently 
that the CTTBtallinv etrncture in the former. 
ia not BO n-gulnr iu> in the liitt«r, or in tiie ej-novial 
metDbntne. I niny hero remark, in concluding thi* 
|Mut of the Bubjert, that in whnU-vcr tissue or »tUH- 
tSoOf urate of soda is deposited, it invariably exhibits 
ciystalliiie appearance, although some-times the 
prtanu are exceedingly small, requiring high magnify- 




* FIc. 24. A (tnwing tnm ■ ■uU p'lWe at arnDiuI nontnuM 
tgum Ifct 1iM«-i(anl, am\tt i>..li.riMd U^ (I) Sbun On »vpmr- 
■MM *U > BifDifjing laiwcr of SO linwr {9) Oa« tt Vit uMllar 
p^to *>4 ■ nu^iriiag p»v(r vt ttO Hamt, MUUtlaf llw crj*- 
lallinc rtraAora. 

«S 



an U0RR1D AN'ATOUr OF GOUT. 

ing powon and tho uso of pokrisod light to dcfino 
tlicm very clesrly. 

Whon dcaoribing the roischiovous conseciueiioes 
en»uig fW)Di acute gout, it was rennirked tliat pernio* 
nent stiffnesa or complinto anchylosU of the firat joint 
of tliG groat toe might occur aftt-r only a few attacks. 
Oil two occaeioDH I hud the opportunity of a«ccrtaiii- 
in|^ the exact condition of the parte thus injured ; in 
ono c&tc; on making a perpendicular section of tho 
bones, an nppcaranco rL-pri«untv(l in fig. 26, was seen. 




Kg. 25.» 

It will he ohservcd that tho cun-od whit« line, iadi. 
eating the portion of tlie joint, is broken ut intervals, 
at if, i^ubiiequeut to tbo deposition of tliu urate of soda, 
the bony Htnioturo of the cup of tho phalanx had 
given way, and the bead of the mctatonuil bcjne had 
been forcibly thrust into it; in Oiwc -1, this change 
hod proecitled much further, an will be s^een from ttio 

* Pig. 20 nprawU ■ pcrpcD>IIcaIu KctiuD of ihe flnt Jobl of ft 
tntl loe vhioli h»i Ikcukk Miehrloxil aflar a tew ttUolu nf (ouL 




CHAlfOES \^ THE ICIDNF.V. 



2S0 



deecription given in Cluiptcr VI. Further on, when 
lUantniiig tlic luituro of gout, vo shall have to nodoe 
die Uatnlity of thiA joint to injur)-, oven in iudividuala 
Bot safforing firom any urtimilur uffoctiou, and thU will 
pnibfilily oxpluiu the cause of its frei^ueiit stiffness in 
gout. 



Bc»g 



CAanffM in tht KU^ttys of Qottly Subjects. — It has 

; been a proralont idea thut somo comiGction oxistd 

lietwoou gout un<i an iilU'rt^t] i<ecri't.ion from tho 

kidncyv, un opinion pruhubly dcrivud from tlio sup- 

I pomd frujncucy of tlio oocurronce of gout and gravel 

^nn tho B»mo indindual, ittrciifjrthened by the fact that 

^■tlitf nii»it common constituent of urinsry grnvel and 

^ftciilcultu is almost identical witli the chalky dopotiita of 

^Pfont. It 18 true tliut gout and gravel atv- frettucntly 

mot ^ith ta tho somu patient, occimioiiidly simulta- 

Dcously, but more cammonly at different pcritHli of life ; 

tbo(«e who in youth voro subject to the lattor, in middle 

bfe and old age frequently suffor from tho foimer. 

Some yeats sbce Dr. Todd drew the attention of tho 

sioa to a condition of the kidney wliicb frp<iucntly 

I in eaaes of inveterate chronic gout, and named 

by him the gouty kidney, but I bdievc there is nothing 

published throwing any light on tho ohangw in thcoo 

organs in pationta who have only Mtflcrt<d Irum the 

acute variety of tho malady. Latterly I have been 

enabled to speak more poutivcly upon this subject, to 

dear up much that fonnerly appeared obscure, and 

to ahnw that cveu xa tho fllightor forms and early 





tan 



UOKBID .INATOMY OF OOUT. 



8tog«8 or gout, the rcnul orgtins become seriously tnt> 
pUcfltcd. 

Tlio so-callvd K*>uty kidney, sudi ns occurs in nd- 
Tuncvd gout, aod in chronic dt^^iiamatiTO nupliritin, 
has tlie following clmractcrs. II i.i usually much orm- 
tnicti-d, ofti'ii not miirc tliiiii ono-liiilf or onf-thinl tho 
natural size, with n fthrivoUcd npponrnnco, tlic capsules 
thictcoiit-d and opaque, nnd the «tirriice granular. On 
Keotiou it is found that the decrease is chiefly at the 
cxpcnHo of the cortical portion, which is sometimes so 
reduced that the pyramid-t almost reach the surfaco of 
ttio organ. 

In 1849, when eximuiuiig the Iddney of a gouty man 
who had died from eomo other disease, I ohttervcd that 
not only had it the ohanu.-t«rs above descrihcd, but Unit 
white streaks existed ohietly in the direction of tho tuU'S 
of tho pyTamidul portion, some, however, worv found 
in tho cortical part ; tho mamilla of each couo alno 
presented Uie apiwuraneo of little whiU> points, from 
deposition in this situation. Dr. Todd in his lecturv 
oil urinary diseases, mentions this fact, and gives on 
accoont of tho post-mortem examination of a goaty 
patient who died from cholera, where the phenomenon 
w«8 obsen-cd by Mr. Cocley. 

The exteiTiAl oppoanmcc presented by the kidney 
in this form of gout is oxhibitod in Plate 4, fig. 2 a, 
and tho section of such a kidney vs seen in the same 
figure, b, where the white point* nnd lines aro dis- 
tinctly shown, us well as the contracted state of the 



^ 



organ. 



i 



CHANOKS IN THK KIDNEV. 



S31 




(Wien the white matter is placed undtT thp mioro- 
aeope, it is found to bo crystalline in structui*. con- 
Kurtiiig of urate of soda id the form of prisms us repre- 
SL-nt«d in the acoompunying woodcut. (Fif;. 30). 
Wlien itie crystals arc 
chemically tested, they 
w at once Kliown to con- 
sist of mate of soda, and 
H to bo identical with the 
H matter which fonna tho 
V naential part of chalk- 
atoDCuii and produces the 
alteration in articular ciir- 
tilagoa, OS they ore soluble ''■<• ^^■* 

to aome cxt«nt in hot water, j-icid the murexidc test 
when heated with nitric acid and iininionlu. and afford 
cryKtallino rhombs of urio acid oit the addition of a 

ItitrvngiT acid. 
The phenomenon just alludrd to, as well as thu 
contracted state of the organ, I have now frL'qucntly 
obflorvod — in fact in all cii^es of dironio chalk-gout 
whore the opportaoit}' of ninkiug oil oxaminatitni 
Bliaa been ajfordod, and of which many examples have 
be«n reooixlcd in tlie last Chapter; it will there 

fbo toon tliat the kidney's have seldom be4^ii found 
to voigh more than 3^. anmetimcs as little ait 2\ 

' VI|. U tvpTMMU lb« njiUt* or Qnl( of Md* in tha prnmUd 
partias«(*(oal]r kMaay. Ubmt Dugni^iDf irawgr 'JIO, uul poluuol 
ll(bt. 

t n« wrfilit <tt Uw bMllt.7 liiatj hM bm dilltnDlJ; otHmUtd 




:!32 



MORBIO ANATOltY OF GOUT. 



TliG contracted state of the Idclocp in gout ha>l 
been noticed long eiocc, though no stress n-as liud upini 
the point mitil witliin the last few years. Mr. Ilenty 
Watsou, in I7S2, whon dpsciilung the autoj>sy before 
referred to, speaks of the kidiieys as small, and filled 
with hydatids (? cysts), and the outer Kurfoec of the 
right kidney covered with little bladdera ; in most of 
the early acc<>unb< of the post-mortem examinations 
of gout)' suhjecte the condition of these organs is not 
mentioned. 

Is not the same slate of kidney found in other 
diseases besides gout !* A.s far as the contracted or 
atrophied condition of the organ is concerned, the 
question miisit Ih> answered in the nflii-nuitiTe, for this 
olteriition is oni> which not imfreqiieiitly occurs in 
certain fonns of ulbuminuriu. A ^imowhnt simlUu: 
oondttioti of iiriuo k likoM-i.si' fuiind iu uiauy ciucs of 
granular disease and ehnuiii; dc-iiiuamative nephritis, 
ita ia the severe forms of chalky gout, both as regards 
the ordinary physical qualities, as the low speoitiu 
grarity, pale colour, nud presence of albumen, and 
Ukowiso ax to the occurrence of granular and waxy 
casts, but I know of no published observations showing 
the presence of the whiti^ streakit of urate of soda iu 
any otlier dJKi^tiHi than gout. I have paid consider- 
able attention to this point, and aided by Mr. W. 



b; Dbwirm. Sgna IwTe oaiuidntd Uuit in Ihc nulc tbs *Tei»s« i* 
•bant H ounoM, kud In tbo ttmtin !> ouucc*. OUicn think that 
4i onntu ii oMnr th« hntllfay ftTH*<*- ^bs l»fl kidnof U gniunll; 
■omcwluit bmier tluui the rigbk 



J 



CUAN'ORS IV THE KIDKEV. 



sw 



Ilickmaii, late ])liy«ivuLii's assistant in Univenity Col* 
lege HospitAl, <>btniiifJ tho results of an cxaminntitin of 
these organs in twonty-tbree c^miiDoiitJvo uutop«ic«; 
the object «f wliiuli vn\s to useci-tain if tlie wliito puint« 
and iitreiLki* wore found in otlivr than gouty oq^cr. 
The exantinationa wcm itcuiiiisiirily made on subjects 
who had died nf vi'i-j* vurj'ing cbusgh, some from 
accidents, but nio^ fmm diHotue; one individual 
had suffered from gout, and here iLo deposits were 
diaouvcred, as ali>o the aifoctiou of thu joints ; in nine- 
teco out of twoDty^two remaining cui^-», no dcpo«itK of 
urate of soda wore discoverpd, but titty loattn-r was 
uoca^ionally obaer\'cd among tlie tubca ; in threci 
hinrerer, ia vhoao joints do I'videncc of gouty deposit 
ma visibte, crystals wcnj seen in tlie kidneys, some 
ootapoacd of uric acid, others of unite of sixht, but all 
of thom situaled within the i\i\xf, and much larger 
than thoM observed in eiu^es of guut, when-, us I hive 
beforo remarked, tlio de{>usit (ifU>ii appears to be intcr- 
rtttial, that is, within the fibniuM ti)«ue.«of the kidney, 
■a if true gouty inflammation had occurred in tho 
orf^ko itaclf. I should not nish at present Ut make 
■ny {wcatire statemeiit on the subject, as I look ujwn 
it as still sub jndioe. Although ci^-stalline deposits are 
Ibund in other subjects than those who have had gout 
in their articulations, }'et tho occurrence is rare, and, 
baaides this, the extent to which it occurs is geiH-rally 
ao Htnall as to require a special examinatioQ to diMOTer 
it, whereas, in gouty cases, it is ver)- appurent. Of 
the abore three apparently oxoeptiuDal cases, two were 



at 



MOUBID ANATOMY OP OOCT. 



t 



mules, 70 and 7.'( yoBrs old ; the other a fcmftle, 68 
yoore of age, wlio died from a buni. 

Having noticed the constant occurrence of it morbid 
Htntc uf the kidney in advanced f^unt, and added, if 
sucli wiTo ncceesar)', additional proof tii the corroct- 
no88 of the ohservatiwna of Dr. Todd und others, 
it beCEune a mutter of much intorost to proceed fur- 
thcr ivith the inquiry, and ascertain whotber in its 
slighter forms the kidnc}'» were also implicntcd, 
ex I bud long been impfLSMHl with tbu conrieticiii 
that UQ altered remit t'^.'iTetion was closely related to 
the diHcufiC. 

In the account of Caac 6, it will bo observed that 
there existed, in a well marked form, the Blmvelled 
oonditiou of these organs, and a deposit of cr^-stallisod 
orate of soda in the direction of tlio tubules ; points 
of tbc same were also seen at the ajnccs of the concfl. 
The microscopic structure was likeu-iso altered in 
the manner shortly to be described. In tliis subject 
the only external evidence of gout was the presence 
of two or three small points upon the cartilage of 
one ear. 

In Case 7 the kidney's were altio considerably dia- 
eased, of small weig^bt, uitich shrivelled in tlic cortical 
portion, and exhibiting tlie white points at the apices 
of the pyramids, and strealui of tbc same salt in the 
direotion of the tubolL MisfTOHcopicolly the etrueturo 
■was much altori'd. 

Ill Case 8 the kidaeys, although congi«ted and 
weighing nearly six ounces each, were grunular tn 



J 




■tructnro, and extiibited the same streaks and points as 
is Case 7. 

The kidn(>)-8 in Case 9 had nndergooe ooosidDrable 
chuiffe, did not exceed three ounces in weight, and 
eofitoincd much nrate of wda about the ends of the 
pymtnidF, ittui in the direction of the tnbea, wliicb 
exhibited the usod micrgscopic qipewmncc. 

In Ciwc 10 tho renal orgnm wero not examined ; 

the oIlMTod inspootion being confined to one great toe. 

^L In Cane II the alteration in the kidneys wits a 

^'sabject of much interest> as only eight attackii of 

gout hadoocurred, and no risible sequels had been tell 

by tliciu. Hero it will be observed the kidno}T! were 

■pparcntly tieeUhy, each weighed four ounoi-^ nn<l 

a half, and the cnpmiles peeled off n-ittiuul dtfli- 

calty ; but when elnscly inspected, white pGints were 

Iband upon the free ends of the pymmida, and 

■tnaka existed, as in the fnrmer cases. The micro- 

■DDpe also rercaled the commencement of other mis- 

cdiief : a portion scut to Dr. O. Johnson, who was 

twaoqnainted with the case, elicited the following 

remarks : — " The epithelium in some of the tultos is 

•my granular, and there arc a few denuded tul)es; 

tlie chief chango in tlio kidney is an excess of oil in 

^^the epithelium ; the outline of the tubes is very 

^■dark, depending on an nccumulution of small oil 

V globules in thu cpittioliul lining." The dcpoeite*] 

orate of sodu was very highly chaiactcristio. 
H In CiusM 12 nnd Kt tliu white stroaks and poiuta 
H wore observed as U'forc 



33« 



UOBSID ANATOMV Of OOUT. 



The only gouty subjects oxamined in which the 
kidiifj's wc'i-e not dlstiiiotly nfft'cted, were Cases 14, 15, 
nnd Ifi; in nil of tlieni, however, tliese orgaos were 
much congested, which would render it difficult to 
det«(!t minute pointi or strcakH, even if present. 

yiTbea I first observed the white points and utivaks 
upon the pyramidal portion of the kidney, I was 
inclined to consider the appearance duo to the tilliog 
of the tubuli uriiiiferi, and this was evidently Mr. 
Cccley'a idea ; subsequent examinations, howcvor, 
Imvo led me to form a different opinion ; the cnr-stols 
of urate of soda, which are commonly much larger 
than in cartilage or Ugamcnt, ofton seem to ho im- 
bedded in the fihroun eitnicturo itself, rather Uian 
within the cavities of the tubules. Further investi* 
gntious on this puint are still a desideratum. 

The microscopic appearances of tho kidney in this 
form of disease have been caiefully examined by 
Dr. George Johnson, and fully described in his work. 
To thiK gentleman I am indebted fnr tim loan of tlio ^m 
slideii from which the di-itwingiH cxhibitiTig tlic morbid ^H 
ap]iearances of the kidney were made. The change 
in the early slata of the diiiciu«e, when the ktdne}*is «re 
still of their natural nixe autl weight, and present to 
the eye nothing abnormal, appears to consist in an 
altered condition of tho epitlielial cellH of the conro-' 
luted tubes, which become opnquo and have an ua- 
tisually fine granular appoanince. Dr. Johnson statos, 
that " LD some tubes th^-ro is on nppearaiico uf fntiro 
cells having bc4>n shed, so us to fill the tubes and 



CHANCES IN THK KIDXEV. 



asT 



N 






render thein opaque ; wbilc in oUiors thpro is an oqunl 
filling Mid opacity of the tubtw, from containing cpU 
tholium in n dL^ntogmtcd condition, nud which hna 
b«conic- m either from tlie cnmibling of tlic wlls while 
they are Htill attached to the biLscmcnt mcmbmne, or 
£rom the disintegmtion of tlie epithelial cells whidi 
haro aocumuktcd in the tules after being »}iod in nn 
«Btint fonn by a process of desquamation." Tlicre 
ai oftoD bcdidett thi-t an excess of oil in the epithelium. 
After a time tlie matter CMiitoiiicd iii the tubes 
bccomefl di>nnti.'^;rated, and gradtuiUy rciiiovod by tlio 
waten,' MWJftion from the Mulpighiun tufts, and when 
this ia cflectod iJie biisemeiit membrane is seen to bo 
left nlmoKt denuded, and from being partly concealed 
hy thtf surrounding fibroii-s 
rings, gives to tlie siction 
B somewhat vexictdar up- 
peRrance. Tlio conditions 
jnst dpfifribcd uru .<hown in 
Fig. 27, where the tubei 
vbich are tilled u-ith tlie 
diijnti^^ited epitlielinl 
celU aro seen to tlie right 
and below; whereas tiif^de- ^<t ST.* 

Duded tubes giving riitc to tlie cystic appcttrnnoc occupy 

* Kg 37 rifTTWinU ih» unilStlon of ttia kMiwT lu (onl uiil md* 
fem* of ■Ibaminiiriit «ri>rin'i? ilrwimxrutliir nrvhiliia). To tl>* Hgbt 
amd htlan (lie tatxi hn lillpil ■ilh ili-iiit^KOt*'! ciullxtUI crIU; th* 
Hjjflc ■pptanne* la iba otbgr pvta ia prultmnl \i] \he ttmailinj of Um 
lata Mi MIDOt*) of ths epllhcljom, tinnr nu^ifjing pmt, 100. 




s» 



MORBID ANATOMV OP OODT. 



the r«flt »f the drawing. After a time, and as a remit 
of tlio removal of th(.< cpthvlium, llio tubos gradnally 
beoome wasted and shrivelled from tho coUiiptio of the 
suTToanding tissue ; by this chan^ the Mulpigtiisn 
bodies approach eiich other, and heiico appt^itr more 
numerous thua u«uilI id the iii'Id of the microscope. 
This change I havo observed in all the COMK of advanced 
gout in which I havL' had on opportiinit}' of oxAUiining 
tlio kidney's, and it is ropresontod iit Fig. 28, where tlie 
__^ atrophied and shrirellod 

tubcA may bo ob^on-ed 
til the right, rutd tlie 
Malpiglkian corpu^ci to 
the left of tbo dramtLg. 

During the time the 
above changes are taking 
ploue in the urinary tubes, 
the blood'Tessels of the 
kidney are undergoing a 
marked alteration, and this 





Pig. 28.' 



is moRi eepcciolly seen in the Malpigbinn arteries and 
capillaries, the coats of which am much thickened or 
hypertmphied. Dr. Jnlmsou says, that both the 
circular and longitudinal fibres become affected, but 
that the longitudinal arc incn-oscd more than tho 
other set, and hence, when diseased, become of about 

* Pig. 2^ from n Mwlinn nf * kiJnpy ia admnccd gnat, nbibitint^ 
In tbi> right, tbt lubta ia ui Btrojibicd uid ihriTiilJed itato, ftnd to tlu 
Uft thv olndoridg toii<tbci^ "< Malpi^hJDii boJica. Llnau mi^nU^tnc 
power, 100. 



E. 



DEPOSIT IN rARlOrs OBOASS. 



I» 



^ 




Flf. 29.* 



njoal thickDess. Hip smsUcst arteriee, ortheofEcrmt 

rcBBcIfl of the Malpigliinn tuft*, are most implicntwJ. 

and audor the niicroscopo exhibit the nppcoranoo in 

Fig, 2t(, where tortuosity 

is often combiued witli 

hypertrophy. Such a 

conditioD of the arteries in 

only seen when the sab* 

stance of the organ i» 

mach altered, and tlic 

itupcdiniciit to the cirvu* 

lotion i^atty increnjtcd. 

Little baa been mode out 
with regard to the state 
id the oapillariw of the kidney, hut they probably 
become n-asted. The walls of the efferent vi^ssel-i or 
veins are eortaiDly not h)-pcrtrophicd. hut, like the 
capiUuriiw, undergo a slow proocss of utropliy aiid 
cuntnivtion. 

VepotilioH of Govijf nmUer in olher Orffana. — 
Oouty cotMrotioDB or deposits have l)ocn 8iud to occur 
not only in the structun-a we have already alluded 
to, but also in rurious other ti-tsui-s and iirgai». Thus 
ilmring found oonerstions in the lungs of an old man 
who had suRen'd froia the diseam in ciueation, but 
there ia no resuun to suppose that tlioy were gouty 
in character, as they consisted of phoitphate of Ume, 

* FIf . n npnnnU Ibo hjrpcTtnphjp of th« M>1|'isliiui uteriia ; IW 
■MMIm- AbfM »n Men to U much nlivtwl, non cqiMikil; Ik* 
' tlpMUr, in tb« dnwlng. Sam* klUntiun of t^a* it nqoiitd to tolna 
1h* Ivn^tadlnal m l»lo tU*. LlDMr a«(>iiQin( (0*M. 100. 



k 



340 



M(»imiD ANATOMY OF OOOT. 



maesee of which v/e know to be far &om anoommon 
in SQch situntioDs in patients who have nevor hiul 
gout. Landcrer found n whito dt-pooit on th(^ intior 
fturfac^ of tho anrta of a gouty subject, but I lun sot 
aware that aiiy chemical analysis of it was made. 

I have carefully examined the deposits found on 
ibe vfdvce of the heart and the atheroma &om the 
aorta of several gouty patients, having extentdvo 
chullc-Ktouc-», hut have always failed to discover the 
Wast tr.)cc- of uric acid ; liut tubular crj-stnls of cholos- 
teriuc are often present in vucli mutti^^r. 

Deposits are stattxt to Lave been found in tlie 
meningvD of tlie bntin of gouty mibjccts, and Schonlcin 
id »aid to have detected urates in them ; th«re is no 
doubt but that they p«nerally consist of jibosphate 
and carhonntc of lime, and probably have do relation 
whatever to tlio disease under consjderatinn. It may 
be remembered that Mr, II. Watson, in his descrip- 
tion of the appearances prcBcntt'd by liis jjcmty patient, 
mcntiona that on the outer surface of tlie pia mntcr 
there WIL3 a cream or smooth chalk-hke mucus. At 
the timo he published his examination, iiothing waa 
koown of the chemical nature of gouty dojiasits : their 
physical chnrnctcRi only were regarded. In many 
otlier observations, the ei-ror ha.'* frequently been com- 
mitted of looking upon all tlic morbid nltenilionx found 
iti the Rwbjocts as neceswarily eonnected with gout, 
wbcrpim they may not Ijc id the mt)»t remulo degree 
allii'd ^) this disease. 

In one case of Tery aevore gout, (Ca-ic 3, Chapter 



DEPOSIT OS ARYTESOID CARTIIiAQES. 



241 



VT.)] I hare obeerred some points of deposit on the 
■zyteooid cartilages, and these were proved to consist 
of mate of soda, both from their microscopic and 
chemical characters. 



3*3 



CAUSES OF 0001. 



CHAPTER VIII. 



CACfBi or Ooct : — rtucctcroiina cil'sm: utREimiHr tunnxci — 

nS — ABt — TKXmAHEKT 03. CUXTtTCtlaXlt mCCLUUTr — 

AbwnoLic Ltqeou—biiTEKiiiCEi n tnitK rowHR or iireoeiiia 
aotrr—txDioxsTioa— A1TIHAI. »iet — abskxcs or nJuouB— 
ninRE stotir— ««iPtit »rii»Tir — clihiti— liu> u a nx- 
DEsroMiia enDBi or oauT— onui miqirKiiQT or mm Dtmm 

AMOKO rJtlSTtBS im VLDHDEIU— mrLORKTI or THR IMaiPnOK 

or uuD crur thk kxcmtioii or omo acip— kio)tii<) cavw: 

Wiru, fco. — DY»Pir!U — OOLD AID HOHIUIUI — KUIUI. AXB 
MDILT IXOITRKKXT OR rXTMnr. 

The most casual observer must at onoo perecivc 
that thero is a great difleronco among indindunlH in 
their liability to gout : eomo aro horn with a well- 
marked predisposition to the diaoase ; otlieis, by the 
nature of tboir occupations or habitd. ncquiro it; nt 
some ngcs it la frcquODt, at others it is rarely mot 
with ; fiomc cnusa'i act slowly, requiring months or 
even years to derclop the affection ; other influences, 
althot^h powerless in induoing the discuc, may in 
BOmo rapidly bring on an nttiick. Tlic causes of gout 
may therefuro be conveniently dindod into two 
dasaos, predisposing and exciting. 

1. Prediapoaiiig Causes of Gout. — Of thrsc, somo 
manifestly depend on constitutional peculiarit}' and 
are inherent in the iitdiridua] ; otht^rs arc &om with* 
out, and are produced by external influcuces. 




HEfiEDITARY PREDfS POSITION. 



US 



Jnjlitence 0/ Hfreditary Prtdisponiion on the Oemr^ 
rente 0/ Oout. — Most writore ackaowledgo this In- 
flaenoe to be vorj- potent, some have even gone tho 
length of cpiisidfring gijut purely hereditary ; snch 
was the opinion of Dr. CuUen ; but that it often is 
■equtrod, wc can bring forward abundant evidence to 
prove. 

Sir C. Sciidumore found that in 523 gnuty patients, 
M nuioy as 309 cuidd traco a predisposition to the 
'f'I't™' cither from tlieir parents or grand-parents. 
AjmI from the rf«ults itrrived at by a. Cummission 
of Uiv French Academy, tho strong influence of here- 
ditaiy predisposition is shown, though in a less marked 
dugrec than in Sir C. iScudamore's ea*o*. Of eighty 
patientB sufiering from acute or chronic gout, tliirty- 
finr ftttribuled the disease to its influence, and in 
forty-six, the malady seemed to have been acquired. 
Among my hospital goutj' patients, 50 per cent. 
could establish an hereditary predisposition to the 
ditcoAe, but when the cases of gout which have 
oocoired in private practice are included, a stilt 
higher per cenlago is obtained. 

On the other hand, vxpcrienco has convinced me 
that gout is frequently acquired in this country, even 
ftt an early age, and in many of the most inveterate 
eases I have met with, the patients could not trace 
the affection, in tho most remote degree, to hereditary 
infloesce. Hcbcrden also relatci an instance of a 
fimule who sufiercd from gout to soch a degree as to 

haro numorons sores &om chalk-stones, and yet tho 

a 9 



au 



CAUSES OF OODT. 



diAeciED liad neTer been Iioard of nmong tier relation^ 
and sovcml oaacs of a siinilnr kind hitTc come under 
my on-n ob«en-stion. One patient, a fomalo only 
thirty-nino jt-ara of ape, who siifTcrod most severely 
from chalk stonos, oould truce no predisposition in 
any membrr of her finnily ; and another fomalo. even 
more crippled, could only o^icriho the disease to tho 
port wine slie had been in tho habit of drinking. All 
evidenco on this subject appears to point tii the fact 
that the children of gouty parents are, cipteris paribm, 
more liable to gout than those who have no soclij 
descent 

A fev years mnce, I was consulted by a gentleman 
labouring under a severe fomi of gout with chalk- 
stones, and, although not more than fifty years old, ho 
had suiFored from the disoaae for a long period. On 
inquin.' I ascertained that for upwards of four cen- 
turies tlio eldest son of tho family had invariably been 
afBict<^d with gout when he came into possession of the 
family estate. 

It would be noedlesa to dilate furtlicr on Uiis sub- 
ject, as all who have bad an opportunity' of becoming 
oonversant with the history of this malady must bo 
folly convinced that heroditarj- predisposition plays no 
unimportant part in its development. 

It is a common opinion, and one with which from 
my own experienco I should bo inclined to agree, that 
the gout appears earlier in life when hereditary prcdis- 
porition exists, than when it b ncijuired. Sir C. Scudn- 
moro once held tho same view, but afterwards found 



INFLUENCE OF SEX. 



*ts 



thatt OR pnttitig the quMtion to the test by the cxami- 
oftttoa of 214 persons who had gout in a very seven; 
dc^grco, he anivt-cl at the conclusion, tlinl nlthough tho 
ioJtu^cc of hcrcditun- predisposition was well murkt'd 
in oousing the nppcitranoc of the disciLse at mi carlii-r 
period of lifo, still that it was by no moans .so litrongly 
shown as he bud previously supposed. Tliu.'i, out of 
tho 214 GOMW above alluded to, 12-1 wero lioreditaiy 
and ninety acquired ; of the hereditary there were 
eight men and two women before tlie age of twenty, 
fifty m<^D and six women between Uie np^a of twent)' 
and thirty, and fifty men and eight women between 
the ages of thirty nnd forty. 

Altiiougfa I have seen many paticntj« nnlTcnng from 
goat in early life who oould not trace the di»ea«^ in 
«iy bninch of their fiimilies, these cases have heea 
all satisfactorily explained by the habits of life, and I 
do not remember a single instanoo of its ooctureiiiOC 
in youth whiuh could not bo thu£ accounted for. 



Xi^utaee »/ Beat i^wii /A* Occurrence of Omtt. — That 
vomim ore Icb Hubjcot to gout than men u beyond 
doubt ; at the same time the nphorism of Hippocratc*, 
" Mulier jjodagrft non laborat nisi ipsi menstrua dele* 
oerint," although possibly correct at the time it was 
written, certainly does not hold good at present ; but 
even at the prefent time, gout i» iti rvgidar and d^ 
Tipped form is comparatively rare among females. 
Tbo TMaon of thL<i immunity enjoyed by tlio feoale 
sex will not bo difficult to imdersland, when we havo 



ua 



CAPSES OP OODT. 



discuseed tbo pi-cdiaposing and exciting causes which 
most powtrfitUy toud to its dorolopmcnt; for wo 
shiiU fiiid that the female eex, from the different cha- 
racter of their habits, ai-e much less exposed to these 
influences ; hesides which, a most powerful counter* 
acting influenco exists in the preaence of the catumenia, 
during a con»^iderable portion of their hvea ; sometimes, 
however, women, altliough quite regular as to this 
discharge, arc iiubjoct to genuine gout. I have seen 
several patients so afTeoti-d, iind hnvc likewise been 
called in to attend cases where, at tlie time of pre^ 
nancy, the great toe and other joints have been 
severely aitnekcd. 

Moirt of tlie foninle caws which have come under 
Diy notice have been iiilieiitod, and I bcUeve that in 
this couiitrj- ncquired gout is rare in women. In the 
degenerate times of the Itoman empire, when they 
gave themselves up to every kind of licontioumoee, 
tbcy appear, from SenccaV account, to havo bocome 
the subjects of gout equally with men. 

In women gout is more prone to assume an asthenic 
form, and to exhibit its marked and irregular maiii- 
festations, and it is ulmo Uablc to appear shortly after 
the cessation of the meustrnttl discharge. 

In the French table before referred to, in 80 cases 
of gout, 78 of the patients were men, and 2 only 
women, and my own experience quite accords with 
these results. The influence of sex on the occurrence 
of gout is so great that it becomes a diagnostic 
mark between gout and rheumati&m, for the latter 



J 



llfFLCEKCE or ACE. 9tf 

is perhaps more fns^ucat among iromen than 



men. 



I 



Ti^ence of A^ npon i^ OeeurrtnM of Ooul. — 
7oatli, for tho most port, cujoys inunutiitT frtniL 
goat. Hipitocrates cxpivssed his opinion on this 
Eabject in the foUomng apbomm : — " Puor podagrfi. 
D>m Inborat, auto rcncris oaiua;" and SydoDham 
itutes that be had never eeen citlier gouty minors or 
children; the most that he bod obwn'cd was tho 
slight foreshadowing uf a. future attach in the younger 
branches of gouty fiuniiifs, Hcbcnlcn, again, never 
know a certain case of gout K-forc tho ago of puber^. 
On the other hand, in^tuncce aro r^tcd in which 
gout i» said to have occurred in verj* young cfaihlretlj 
bat I lun of opinion that in many of these eases 
coostderuble doubt may bo entertained as to tho 
conxxitncas of the diagnosis, for in " young " subjocta 
other joint affections, especially rheumatism, may 
reudily be mUtaken for gout. 

!I1io jwriod of the first attach was noted by Sir 0. 
Bondamoro in olo cases, and the results of his 
inqaiiy are seen below : — 



At tiM 4* of •Ifhi 

Ivalv* , 

fiftMU 

■iilMa . 
M««alcsB 

tl^tNtt 



M«Ma twtnlj wd ivralj-Sr* jnn graft 



■8W 



CAUSES OF GOUT. 




Iktweeii lliLrtj soil thirtjr-Sn 


JMIB 


ofaC( 


JOE 


,, tliirtj-lirc anil forlf 







89 


„ Turlj aati furly.lii'O 




•t 


et 


„ fortj-Ett mill fifly 




„ . 


S( 


„ fifty ftnd fiftr-fiire 




•• 


« 


„ ftft;-dr« uiJ liitT 







IS 


„ lUtf wd aiilj-flra 




>■ ' • 


8 


AiUi«a«ottixtr-*is . 




. . . 


s 



as 




Sir 0. Scudamore, in alluding to the above t«ble, 
lemarked that ho bad not himself witnessed many 
examples of a first attack of gout before twenty, nor 
any after sixty-six. 

It vnW be observed &om the above, that in adult 
age after the growth of the body is complete, and 
before the powers begin in decline, in by far tiio 
majority of eases, gout makes it* appearanoe ; when 
the iJ^ is measured by decennial periods, the greater 
number of cases arc found to occur between tfao 
tliirticUi and fortieth year. 

Some years since I was called upon to treat a first 
and only attack of the disease, in a gentleman at the 
ago of Eevonty. The patient was suffering from 
valvular disease of the heart, witli dyspniua and 
anasarca of much aevcritj-. Early one morning, and 
at a time when there was scarcely any anasarca, the 
hall of the left great too became hot, swollen, and 
painful ; after a few days the fit passed off in the 
u-Hual mannei', and was succeeded by des<^uamation of 
the cuticle. During the time the gouty symptoms 



J 



ISFLITEITCE OF AOB. 



su 



wr-ro present, mftrkod rdiof in tiie brcatlung was 
■ xpcrienocd. 

Within tho last two years T liavo knovn sorenil 
oases in which the fiist attack occumsl iiftor wrenty 
ytnnof age, and Sir R. Blackiiioro relates lui instance 
of a gontlomun of vigorons conatitutiiiii, in whom goat 
occurred for tho Jirst timo at tho ad^iuocd ago of 
flevcnty-cight. 

A short time EiDce I vts constdtcd by a young gentle* 
man, only seventeen years of age, just recovering from 
s second attack of gout in tL« left ^n^iit toe ; hiti first 
fit had occurred about twelve montlis prc\"ioualy, and 
Iiod affcvted tbe ttamc joint. In thitt instance the 
inflaonco of hereditan- predisposition was very strong, 
both father and mother and many niombcrs <rf 
his family on each »ido hfix-ing HuSercd bwa the 
atalady. 

SevomI patients liavo recently tiiformrd me that 
tiiay hod experienced distinct attnoks of gout at very 
«ariy ages, when tlicy wore pupihi at tho public 
■ehuoU; one gentleman, now a wvere sufferer ftxim 
goat, nasures me his firrt attack occurred at nine, h» 
Moood at twelve years of age. 

Ftoticnts who inherit gout soffer from its attacks 
at on earlier age than when it is simply acquired ; 
for example, in the French table previously ivfbrred 
to, tho mean af^ of tho thirty-four cofto-s of hereditary 
goat via thirty-four years, the extremes being thir- 
tocn and sixty years : whereas in forty-thrc« oat of 
tho forty-inx coses of the acqnired discaw. where tbe 



h 



Mil CAUSES OP OOCT. 

ngc is notecl, tho moon is tMrty-oigbt jcars, tliC 
extremes being hrcnty-suvcn and fifty; my own 
L'Xpt'rifuco fully confirms this. 

Between goiiuiiio gout and rlieiunatism, as t}'pified 
in c&st'^ of rhcumntiu fovcr, n marked distinction is 
seen in the influence of ugu ; llie former occurs moat 
communly for llio first time after tliirtj-five, tho 
latter \a seldom met with when that period of Ufo 
is passed. 

Infiucnee tf Temperament or CoiutHtitioital PcchH- 
ariiy on the deeclopnitnt t)f Gout. — It must bo remem- 
bered that the ancients, from the time of Ilippocrates, 
held tho opinion that thero (.'xi^tcJ four kinds of 
humours in the human body, — blood, Lili', black-bile, 
and phlegm, nnd that, as ono or other of sucb humours 
was supposed to bo presuut in excess, tbo indi^^d^al 
was said to be of a sanguincouB, bilioo), melancholic, 
or phlegmatic temperament. Thow tenne, though 
still employed in medicine, oro used with little pre- 
cision, and much reliance cannot bo placed upon tho 
indications they are supposed to give. Tbo terra 
"nervous temperament" is also ucetknoually employed, 
and by it a peculiar irritablo condition of tbo nervous 
system is understood. 

Witli regard to the iiifluonco of tbo so-cttlled tcm- 
pcrameut upun the occurrence of gout, I hiivo littlo 
information to otTor, having derived nothing satis&c- 
tory from my own observation, nnd baii'ing met vrith 
the disciuo in individuals presenting every variety of 



I 




i 



ISFLnENCE OP TEMFERAMENT. 



351 



I 



bodily confonnntion. In general tenns it mny bo 
Mud that ncutc sthenic gout occurs most &cqiipitt1y is 
subjects of a sanguine tcmpcnunont, and those inclined 
to corpulency; whereas tho asthenic and irregular 
Ibrms are uimatly seen in individuab of the iterroua 
temperament and spiuv liahit of body. 

Dr. CuUeu modo the following ohscrratians on the 
influouoo of temperament: — "If, with the ancients, 
wo might ii.<«ccrttiiu by certain tenns the temperaments 
of men, I could 83y that the gout sttoeks especially 
max of a cboIerio-saDguino temperament, and that it 
seldom attacks tho pure sanguine or mclaucholic. It 
is, howOTOr, very difficult to treat tins matt<'r with duo 
preciidon." And in another placu he tayf, " It attouks 
cspecialty men of robust and large bodies, men of largo 
beads, and of full nnd corpulent habits, and men whose 
skins ore cororcd with a thick rete mncoeum, which 
gtVM a courser hutTucv." 

Tttfluenee ^firmenlfd and distilled liquors in indwing 
OoMt. — Tbcro is no truth in mcdicdno better established 
than the fact that the u»c of fennented hquors is the 
moat powerful of all the prodi^Lpo^n^ cuui<c« of gout; 
any, ao powerful, that it may be a que-stiou whi-tlier 
gout would ever have been known to mankind liad 
aoeh bcveiagea not been indulged in. 

A conHderable difference, however, exists between 
the Tarious fermented Uquors in their power of in* 
dacing gout, ond many interesting observations and 
fluitB am bo ehdtcd in relation to this point. 



«1 



CAOBBS OF OOUT. 



On &e first coneideratiDn of the question, it voidd 
be natural to suppoac that, as the great poculiaritj- of all 
fermented liquom consLst't iu tlie alcoliol thoy contain, 
their power of cau^ng gout would be in proportion to 
the quantity of spirit in tlieir composition, but a room 
oareful investigation of the l^ubject foils to establish 
Uiis suppoeatioii. Distilled spirits, when oxclunivi-Iy 
taken, appear to exert littlo or no power in induoiDg; 
gout ; whereas wines, strong ales, and porter, arc potent 
agents, a fact which is forcibly imprtssscd on the mind 
on taking b review of tlio prcvolcnoc of the disooso ia 
diSl-rent countries and among different classes of 
individuals. In Scotland gout is much loss froqueatlj 
met with than in England, and I have been SHured 
by physicans of note in that country that they very 
aeldom sec a case, and when it does occur it is gone- 
rally iu the upper classes of society aud in large dties, 
where wines aud ales hove been largely substitutod 
for whiskey. Dr. Gregory, at the Uoyal Infirmary of 
Kdinburgh, had only two cases of gout in two thou- 
sand two hundred clinical pationU admitted under his 
care, and ])r. namiltr)n, during nearly tliiity years, 
hod likewise but two Ruoh patients. Dr. Christisoa 
beora simiUir testimony, for ho informs mo that ho 
only met with two oases of gout in the .''nnic infirmaiy, 
although physician to ic for thirty years, and both the 
mibjectd were fut and overfed English butlers. The 
same frccdoni from goat is equally bnjo>'od in other 
Scotch cities, as Glnfi^w and AberdcoD, as UkcwiMt in 
Ireland, whore whiskey ia the principal l)C%'eni^ ; and 



INFU'EXCE OF ALCOHOLIC DRINKS. 



SS3 



Banana Polce, and Danes vho usually drink distilled 
spirits, alao CDJoy coniparAtivc tmniuuity from gout. 

Ton Swicten states that in Tlutland ^ut was bnt 
HtUe known until wine was intrudttci'd as a substitute 
lor bocir ; and Linoieus, from his oliservution upun the 
bAbitfi of the Laplanders, wa.i inclined to regard wine 
08 alm<)»t the snlo producer of g(>ut, aa the people par- 
fuok of malt liquors with impunity. 

ThcM! fttutonioiits of Van Swieteo and Linnceus 
merely render it probuble that wine is more powerfiil 
io ptwlucinp gijut than the beer drank in those 
countries ; we .^hllll hoou have occajsion to show that 
matt liquors, more i-spcciidly the rtrouger varieties, 
■re most potent predisposing agents. 

Many bets arc on record «howiiig the relative 
powon posMSScd by spirits, wim-s, and molt liquors, tn 
tliifl rotpect. Sir 0. Scudamoro gives on ooeount of 
two pttionto illustrating the pouit. Tho first, that of 
a strong and corpulent man, about 34 years of age, 
who bad been »abject to gout fur five years. In tho 
earlier pari of lib life he had been constantly on the 
9eft coast OS a unuggh-r, und hud drunk two or three 
pcnta of H(^ands a day ; this was continued daring 
ft period of four or fire years, simply with the effect of 
making him somcvhat nervous and dyvpeptic. Ho 
aflarwanls became a bricklayer, and being poHused 
of propoit)', indulged both in wine and porter, taking 
only a small quiuility of spirits ; in two years after 
be hnd commenocd this new mode of tiring be was 
attacked with goot 



S51 



CAVSES OF GOUT. 



In tlio eocond instance the patient lived to tho 
couutry until he yras 28 years of nge, and partook 
freely of HoUandE. He tLen cngagi>d liimsdf as a 
butler in Ivondun, and indulged freely in wine utd 
molt liquors. When Iio came under treatment ho ', 
vus 59 yecirs of age, and during llio lust ^4 yean had 
had an annual attack of gout. In neither of the 
above mentioned caaos did the slightest hereditary- 
predisposition exist. 

Agftittst tho deductions which might lie drawn from 
tliesc two coses, it may fairly he urged tbut, with the 
cliango from s[)irits to midt hijnor* or wine, there waa 
likewise cousideruLlo alteriitiou in Imbit^ and occupa. 
tions, and that the patients were approaching the age 
at which gout commonly manifests itself. 

A striking example, illustrating the same feet, has 
been recorded by Dr. Wilham BuJd, who states that, 
" There is a body of men employed in the Thames, 
whose occupation it is to raise ballast from the bottom 
of the river ; as this can only bo done when the tide 
is ebbing, their hours of labour arc regulated by this 
circumstance, and ^-ary through every period of night 
and day. They work uudcr much exposure to incle- 
mencies of weather ; their occupation requires great 
bodily exertion, occasioning profuse sweating and 
exhaustion. In consideration of thLi, their allowoooe 
of liquor ia very large ; each man drinks from two to 
three gallons of porter daily, and generally a con- 
eiderable quantity of spirits besides. This immoderate 
consumption of liquors forms the only exception, as far 



J 



ISFU'ESCE OF ALCOHOLIC DlllNKS. 



iss 



as relates to food, which these tnea offer to the 
goaeral habits of the lower classes, aud, although not 
m uumerous body, mauy of them are yearly admitted 
to the Seamen's Ilospital Ship affected with tliat 
diMMSe (gout). This is a very intei'estiiig fact, and 
tHilill to show that no amount of bodily exertion is 
•deqaate to counteract the influences of such large 
doses of porter ; tho exposure of lallasters ta wet and 
moiataro s«ems to favour iba operation. These men 
arc almost all derived from the peasantry of Ireland, 
thvy can raroly Lhervfuro inherit a disposition to 
gout." 

My own experience of the relative power of olcohoUc 
Uqoora in inducing gout, may be thus stated: thowincfl 
ordinarily drunk in this countr)', as port, shem*, and 
other stronger varieties arc most potent in tlieir 
(^emtion ; but tho fact must not bo lost sight of, that 
those who ait) iu tho hubit vi drinking mne, are, at 
the same time, ublv to procure other delicacies, and 
etpeaally the luxuries of the tuble, ttdditional circum- 
atanoee greatly favouring tho development of the dis* 
o«se. A fovr years' liberal indaJgonoo in port or slicrry 
wine will ofleu of itself produce gout, when no here* 
ditary ti'udcucy exists) ; uid even among tho labouring 
dassM this fact may bo occasionally observed, when, 
from tho peculiar mitiirc of their occupations^K)clIar- 
men, bottlers, &c, — mou havo opportunity of taking 
wine in conndomblo quantitios, 

Tho lighter vin««, as durd, hock, mo«cllc, and 
dum^ugne, although capable of acting as tho exciting 



m$ 



sse CAUSES or oorr. 

CMUO of an attack in gouty subjccU, have, vke 
token in moderation, but comparatiToly Uttle indiicmg' 
power, and in this respect rank with the weaker 
kinds of malt liquors. The wino-drinking population 
of Franco and lUieuiiili Qcrmauy are but little 
afflicted witli gout, and tlie 8unic liolds good with our 
own agrioulturistx ; but when the finer qualities of 
these winct) arc freely partaken of, especially if com- 
bined with cxcceis of animal food, gout is by no means 
lanly in mniiif(:«ting itself. In some of the larger 
cities of Prance and Germany gout is common, 
although considcnibly lens so than in England, and 
in Bavaria and Bcrliu, where a large amount of beer is 
drank, gout al«o prevails. 

Stont and jiortor rank next to wino as predisposing 
causes, and itonio of the most «cvcrc and inveterato 
forms of gout 1 have met with in ho«ipital practice 
have been in patients who hud tliu.i acquired the 
disorder ; such, fur example, arc tho cases occurring 
among the men connected witli tho great London 
breweries, who nut un&cqucully drtuk an almost 
fabulous quantity of malt liquor. I hare notes of 
the case of a man, 28 years of ago, suffering from 
a si'vere form of the di»uiso, attended with a deep- 
seated gouty abscess in tho foot, wlio assuwd me that 
be bod seldom taken less than three gallons of porter 
during the day, often more. 

Strong airs, and oven tho ordinary bitter boert, 80 
commonly ui^jd at the prettent day, c-xert a amilar 
inSucuov, u oxcmpUfied in the following inatauco. A 



IKTLUESCE OF ALCOHOLIC DBlinra. 



SET 



patient only SO years of ago, connected irith a palo- 
jj<* krcwcn", ojnsultod mo a few years ago ; te had 
had his first attiu'k of gout four years previously, at 
tho tgo of 20 ; it was slight, and confined to the hall 
of the right groftt too; three years afterwards ho 
safforrd from a soittc fit of the disoaso, implicating 
not only tlic toe bat the ankle, heel, and knco ; during 
tiu) twetrcmonth prorious to my itccing him, the 
aitaeks bad beon frequent, about every thrco months, 
and won> oanuning n chrome form. In this ease no 
hereditary tendency oould be dUcovcrt'd in nny branch 
of the &mily, although carefully sought for, and the 
disease appcarod lu have been induced simply by the 
habit of repeatedly drinking pole ale in small quan- 
Utios at a time, altliough the total amount in the day 
ma considerable. 

Cider and similar Lcroragos act to xomc extent at 
predisposing causes of gout, although probubly a moeh 
larger quantity of them is required than of tho stroogor 
kitkds of malt liquurs. In Devonshire and Horolbrd- 
ahirc gont, as far as my own experience enables mo to 
jadgc, is by no means infroqaent. Dr. Wood remarks 
that, as a prfdUpoung cause, cider cannot ho v*ry 
potent, olherwiso gout would have been more prora* 
lent among tho people of Nen' Knglnnd, and the 
aiddlo AUantio State*, where this drink was reiy 
cmnmonly employed. Of tho power of cider in n- 
citiHff a gouty paroxysm there can be no qoeation. 

Having fully detennined the fact that tho various 
liquors 1W99C93 different degrees of potency 



2SS 



CAUSES OF GOUT. 



in caosing the development of gout, it next becomes 
interostuig to inquire tlie rcosuu of sucli difference. 

Wliy arc distilled spirits \css prone to induce gout 
tban those which hiivo simply undcrgono the process 
of fermentation ? Their influence ccrtuinly bears no 
direct ratio to the amount of alcohol containiHl in them ; 
for the same quanti^ of spirit which in tlio form 
of port wino is capable of developing tbc disorder, is 
completely powerless if taken in the fonn of whisky ; 
and thu same holds good when the comparison is modo 
hetwoeii strong mnlt liqaoi'3 and spirits. 

Is there any known difTorcuce in their compoaitioQ 
to account for this ? 

Distilled liquors, as brandy, hotlands, whisky, pn, 
and rum, contain alcohol end water, sometimes united 
vdi]\ small amounts of colouring substances and other 
matterK to which their peculiar aroma and tssto bro 
due; the amount of absolute spirit varying in the 
different varieties from 40 to 70 per cent. 

Wines, on the other hand, beside spirit and water, 
contain sugar, gum, extractive and albuminous matters, 
certain £rcc odds, as tartaric, racemic, malic, and 
acetic, tartrates of potash, lime and magncsiai sulphate 
of magnesia, common salt, and traces of phosphate of 
lime ; in addition to these, especially in Iho cellarod. 
wines, the organic compounds which impart aroma, as 
omanthic, acetic and other ethers. In some, tanoio 
acid and colouring substances are also found. 

As the nature and amount of tltc^e different prin- 
ciples are liable to considerable variation, some arrange* 



1 
J 



INPLPENCE OF ALCOHOLIC DRINKS. SS9 

mont is gniu[)3 muy bo iulv«iitugcouaIy adopted. Th«y 

an Hunt cltumificd by Huldor : — 

1. Swoot, or liqueur vriuea, as Hnltiga, Tokny und 

Madcini; somo of these are rich in £ii)^r, but 

Uodcitu coatains no excess of this priodplc. 
3. Acid, or har^ wioes, ricli iu tartaric Hcid, but ]XM>r 

in sugar, inotudicg; the Rliiuo wines (Uoolu), atid 

Moselle. 
3. Spirituous wioes ; as Port, Burgundy, and Sheny. 
i. W^ioes ooutaining tannic acid, tnoludiuj^' mo«t of 

the French winds (Clarets), and reecmbling sumo 

in No. 3, with the exception of containing lees 

■loohol. 
A, EG^veeoing wines ; as Champagne. 

As £ar OB the quantity of alcohol is concerned, — 



*PMt*iBM . 


_ 


■Tongo 


of llkioilt 


:= 


)9-S 


ptTceot. 


Haddn . . 


, 


ir 


IJ .. 


■= 


IS-1 


IV 


T«ii«riii» . . 


> 




la .. 


= 


IS'S 


>t 


BhiMmnM . 


, 


tt 


11 .. 


= 


104 


i> 



Tho amount of alcohol in Fort wines I'arics from 17 
to 21 per cent. ; in Madeira the quiuitity is much the 
Buno ; in SautAnio it rories from 12 to 15 per cent. 
In red French wines, &xtm 9 to 14 p«r cent. ; in good 
Bordeaux, 10, 11, and 12 per cent; in Burgundy, 
B, 10, and 11 per cenL; iu Champagne, 10 and 11 
per ocat In Rhine wines, C to 12 per«»it., generuUy 
from 9 to 10 p(ff cent 

As regards acidity, Dr. Bonot^^ Jones hasasoerteincd 
that wines may be orrongod is iLo feUowing ordor, 

it 



«ta 



CAUSES OF COL'T. 



beginning with thu least acid : — SLcrry, Port, Chnm- 
pagno, Clarut, Miidoirci, Burgundy, Rliinv wines, and 
MosoUo. Tho Icnst ncid of all tdcuhoUu fluida are 
OcQora and Whisky, Uicn Hum and Brandy, ftftor- 
warda Ale, PrirUr, and Stnut. All Oie n'ines nre 
found to he more acid than malt liquorH. 

The following was ascertained to lie the order vbon 
measured by the amount of saccharine matter, I>egin- 
ning with the least nwcet: — Geneva, Rum, MTIiisky, 
Claret, Iturgundy, Rhino wines, and Moselle, Imvo no 
sugar; then Bmndy, 8bOTTy, Madeira, Champagne, 
Port wine. Cider, Porter, Stout, Malmsey, Ale, Tokay, 
8anio», Paxurctc and Cyprus. 

Does our present knowle^ige of the rolfttivc compo- 
Btion of tho different kinds of alcoholic liqiiont throw 
any li^ht upon their varying powers of induciDg gout ? 
So much, at least, is proved, namely, that it is ^ot 
simply the amount of alcohol in Uie fluid, which 
dct<-rniiD(« the result, for we liavc shown that whisky 
and other dl'tilk-d spirits have little power ; at the 
same Hmr- it will he obsen'cd tlmt the wines richist in 
Bpiril \\y\ II iiiilly tlic most pnt4>nt prodisposcn to tlio 
disease, as illustrated in tho case of Port. 

The presence of acidity in alcoholic fluids oaanot bo 
looked upnn as having much inSuenco, seeing that 
Port and Sherry are among the least acid wine«, and 
that strong malt liquors, usuolly freer from acidity 
&Bn wines, nre jiowerful predisponng agents ; on the 
other bond, the more aeid winOB, as Qarets and Hock, 
arc companitively harmless in this respect; in ex- 



J 



INrLL-ENCE OF ALCOHOLIC DR1NK8. 



901 




a paroxysm of giiut, it is probable tliut tlie 
UDOtmt of acidity is of mucli moment. 

The quHntity of euffar can bardly be considered to 
czdrciBc much effect, for it cxiittd in lar^^o quuntitiofi 
IB i!omo of the most potent gout-indudng liquors, in 
■aaU amounts in others, and certainly no direct ratio 
out be established between the presence of saoohsiixie 
jBatter and the predisposing power of any alcobolio 
bcTcrage. 

But little is knova le^ecting the aaline maliert of 
winos and other liquors; it is probublo that the alka- 
line 8«lt9, especially those of potanh, more abundant 
in tlie lighter vines, and which produce diuresis, may 
in some way I«sen tJieir injm'ious oBbcts. 

From our jiix'seut state of knowledge the following 
are the only conclusions which can bo safely drawn in 
nfeienee to this subject : — 

1. Diluted alcohol, in the foiTU of distilled spirits, 
hun little power in causing gout, at least in thoeo who 
are not prtdisposcd to it. 

2> Alcohol when iu combinutioD with other nifa- 
■tenoes, as in wines and mult liquors, becomes a potent 
OawD of gout, and the gix-atei' the amount of contained 
spirit in each bevengcs, the movK powerful tlioir 
influeneo in produdn;; thu diseajc. 

3. Neither the acid, sugar, nor any known priuciptc 
oontaiaed in thoeo liquors, can as yet bo proveil to im- 
part to tiio alcohol its prediifposiug influcuoe; fbr 
winee the litist add, and liquor* the Icoat Bwoot, aio 
often among the ntoet baneful. 



S«3 



CAUSES OF OODT. 



To whidi WB may add, witli somo pi-obability of 
truth: 

4. Aloobolic HuiAb which have Iittk> tonJcncy to 
cauM! djiipepsia, and tliostn which n<rt more rspcciuliy 
as dluretjcsr can, as far a^i gout U conocnied, be toJcon 
with jrroati?r impunity than hpvoriigos of an opposite 
diameter. 

It must be borne in mind that our remarks wfth 
rogard to distilled spiritis apply simply to their littlo 
influence in the production of gout, and it must not 
for a moment he supposed tliat tho^c liquors arc Ices 
pernicious in other rospi'cts than winosj on Uio con- 
trary, the occurrence of gnuiular kidney and dropsy is 
cxL<eediti;:;1y common among populations who drink 
them lai^ly. 

Indi^fstion, animal ifiel and abtence of frerewf. — It 
is often a tnsk of much difficulty to separate the effects 
of the abovc-nnmed influences, as (h'spop^a is com- 
monly induced by tiikiug too much food, and it 
may be equally caused by u want of sufficient bodily 
exercise. Cullen remarked that gout seldom attacked 
persons employed in constant bodily labour, or those 
who live much upon vegetable diet, and few would 
fcel disposed to differ from him in the general truth of 
the statement, for it is rare to find gout among a rural 
population, where much toil is endured, and where 
meat forms a comparatirely small proportion of the 
diet; on the other hand, its occurrence is frequent 
unobg those who freely partake of highly seasoned 
diahee^ and who arc in the habit of consumiDg a quan- 



J 



IKPLUENCE OF nTOlOESTIOK. 



Ml 



tity of natrimcnt far atovo the roquiremcnts of Qw 
S)-stcm. This may be acomnted for hy the fiict Ui«i 
an cxcosB of fuod, more especially when highly nitro- 
geaiscd, fuvuurs an incre^Hoci formattoo of urio acid, 
which hits ulrcady be«n sboim to boar a dose relation 
to the (IcTclupmcDt of gout. 

Not only doos an undue amount of food predi.'ipoMto 
gout, but tlie manner in which it is ass!milnti''(l hfis also 
an influence ; when the digeetive function is impcrfoctly 
performed, the disease is more apt to become devc- 
loped. Sydeiihiini from Iiis own enpiTioncc ciimo to 
the concIkLtlon that gout aHi^cs from what he termed 

weokoiiod coupoctiou both of the solitls and 9uid!<, 
id alUiough we have brought forward evidence to 
show tliBt defectiTC excretion plays an important part 
in it« production, wc must not loiMi sight of the very 
powerful influence of imperfect digestion and o-ssiui- 
lation. 

It is a mutter of interest to inquire what nro the 
varieties of djspopoa which, by long oontinoanoe, 
give rt»e to the gouty diathosu nud the derdopmcnt 
of the local aifecdon. I believe the answer to be 
flunple. Many of the forms of atonic indigestion too 
almost inoperative in this rt-spcct, as they merely pre- 
Tent the proper formation of chyme, aud henco only 
impatr the general nutritioii of the body ; but those 
Tsriotios of dyspepaa which lead to the csocssiv© 
ionnation of uric acid in the system, tend powerfully 
to the production of gout. Clinical observation has 
ooDvinecd me of tbo truth of tliis statemcnti for I find 



301 



OADSES OF OOOT. 



that in somo forms of (lyspopaa, the formation of urio 
aoid is eren below the healthy stoncUrd, but in oUier 
forniB the amount is greatly uugmcntod ; it is in the 
latter varieties only that wo can anticipate tbo dcvelop- 
mcat of the- discAEt', and these iiregciicTaUyaoconipanied 
with eltiggifh circulutiou in tiiu portal ^stem and 
«Blge«tcd liver. 

It must bo borne in mind that in gOUty oaae^ 
ospeciully whoro many attacks have already occnrred, 
litilo Guu be dctcmiinod with ti'gard to the nature of 
the dyspepsia which laid the foundation of tlie disease ; 
for as muI-a«siiDtlutiun may lead to the production of 
uric acid, so au excess of iirio acid circulating in the 
blood may itself pve rise to a secondarj' form of 
dyspepsia, and cause many of the premonitory symp- 
bmifl referable to the digestive organs, so commonly 
met with in gouty subjects. 

The more pi-omineut sjTnptoms of tho dyspepsia 
connected nith the uric acid diathofde may be thus 
summed np : beartburu and eructatioiis, oppression, 
nud frequently sleepiness after food ; a feeling of dis- 
tension in tbo epigastrium, at times accompanied with 
tondenuies ; some fulness over tbo hepatic region, and 
the edge of the liver projecting a little below the ribs, 
and occa^oniiUy tender to tbc touch; tho tongue 
mocb funod, red at tho tip and edges, a disagreeable 
aad clammy taste in the mouth, and the saliva and 
buccal secretion often more adbcjivc than natural. 
Tho bowels arc usually confined, scybalous, sometimes 
very dark in appearance, at other times light and clay- 



IKFLCESCE OF MEKTAL EXEETIOS. 



au 



coloured, fiboviog n dcfcctire oxorotioii of biliar)- 
Dutter. Acoompuiying th«no symptoias there is a 
scanty Fvcietion of urine, which la high coloured and 
acid, and givi-s rise on cooling to a copious deposit of 
uratce, or to a scdimcut of crystoUiscd urio acid, 
varying from a brick-duet red to a pole ydloT. 



Infl»aiee ofsemv atudij and menfat awtUtg, ^c, Sfe. 
— ^Thut the condition of the mind has a povrerful 
tuBueiico upon tho muniior in which tho fimctions of 
tho various orgiiiLs of tbt* body o.rv poribrmod, is at 
gnoo rciiilt^'n^ tvidi^'nl by wutcJiiiig '\ii cfieot upon tlio 
digwtivu and rvual uri^ns. It is not uooommoo to 
find that n scvciv Gt of indigestion immediately follow!) 
till' rpoi'ipt of jKiinful intolligcnw, nnd most pcoplo aro 
eogniiuiut of thv intimuto rotation <-xi»ting between 
tiw state of tlic laind nnd Uic secretion of tho kidneys. 
As powerful and sudden inBoenccs rapidly cfibet 
■pprociiiblo chftnge.s in the diifirent functions, to 
those less marked act as surely, though impcToeptibly 
for tho time, in altering the genend nutritive prooonoa 
of the body, and in the end produce great and laetiug 
miaohief. Serero and prolonged study, which is 
■ImaBt nocessarily conjoined with a sedentary life, 
tends greatly to lower iho tone of tho excretoty 
origans, espcdnlly of tho kidneys, at the same time 
that it impairs the powers of digcstioD ; hence ensow 
not only a dcfcctiTe excretion of some of tho principlaa 
of the urine, but likewise thvir increased fonnation, 
ciroonutanccs which powerfully engcodor an impure 



3«« 



CAtrSES OP OODT. 



oonditinii of Uio blood. There are many cases od 
record, among men eminent for their talcnta and 
application, which couid be bniught fonrard in proof 
of the influence of meutiil labour ia cnusing the 
dcrelopmcnt of gout, and likewise in exciting its 
attacks ! but it will suffice to quote the words of Sydro- 
ham in bi.i letter to Dr. Short, in wliioh he says, " I 
Bond you a «hort tract upon Gh)ut and Dnipsy, i&Rtead 
of the thicker volume, which in my own mind I had 
determined on, vix., a luiitory of Huch chronic diseases 
38 my practice has most especially met with. Bf 
applying my mind, huwever, to iti utmost, and by 
bnnfpng all my powers of Ihouglit on the subject, I 
brought on a fit of gout, such M I had never before 
suffered from ; so that tlic fijct it*olf warned mo to 
lay aside, even against tny own will, Ruch lucubrations, 
and to take care of nij"sclf ; well satisfied with hav- 
ing, in some measure*, dealt with those two diseases. 
Whenever I returned tu my etudio^ gout returned to 
Bia" 

In another part of the same treatise the author 
states that more wiae men than fool.« suifer from gout, 
and from thin and like evidence but one opinion can 
be arrived at as to the influence of severe and pro- 
tracted mental exertion on the devilnpment of the 
disouo ; at the euno time I believe that such cauM < 
alono would bo inoperntiro, unless aided by herediluT 
predisposition. In relation to this subject. Sir C. ScQ- 
dflmciro remarks, that " the late "Mr. Pitt and hisfathcr 
suffered from gout at an early period of life. Tbn ; 



IKFLCfEKCE OF UEPBES8IK0 CAITSBS. 



VT 



father was a votary tn DoccHur ; of the son this ooutd 
not strictly be said : but both wero ardent studenta." 
It it also & well-known fact, that in this country at 
least, cabinet ministon and politicians most distin- 
guished by their tulonfat and assiduous application, oro 
frequently severe nartyTs to Uio disease. 

Other powerfully depressing infiuenccs, as sorrow 
and oha^rin, act in eiigcndonng a gouty habit ; thus, 
reveraos of fortune have Iwen known to do so, although 
tisually accompanied by oircamstances which might bo 
sapposod to prevent its development ; the same has 
been asserted of other mental emotions. 

The influence of venereal excises in the prodoo- 
fioD of gout was much insialvd upon by early authors. 
Hiiipocratett' apliorijon roluting to this point h only 
partially true ; were it literally correct, eunuchs should 
be altogether free, but Galen assures ns that in tbe 
time of the Roman empire they enjoyed no exemp- 
tion. Youert-al exccns, like all other dopreastng 
agencies, lowers the function of the nen,'ous systaut 
and hence fikvours the production of the malady ; 
but it« real influence is the more diffindt to 
scpnrnto and define, inasmuch as it is frequently 
nssociatiNl with immodoratc indnlgencc in alcoholic 
liquors ; henc« the lines of the Greek poet in which 
Oout is dc«cri1)ed oa the danghter of Boocfaos and 
Tonus. 

rAaaroi At^ry, kimin*, ifi tltlir)pa, 

lu tlto treatment of the chroaio forms of gout it is 



3«S 



CAUSES OF OOCT. 



of moch importance that Uie effects of thoM various 
depresaing causes ahould not be lost eight of. 

J$\fiwnce of climate and toMon.— It in u very diffi- 
Bult task to iaveetigato accurutely the rc«] effect of 
olimato upon the devcUipment uf gfiul, fur ao nuiny 
other influences are eoiuiect«d with climate, that the 
BOparation of one from another is rendered almost 
impossible. There are, however, oeituin CacU which 
appear to be well cstablLshod in raktioD to this 
sabjoot, of much interest, and not devoid of impoit- 
anoe. 

Gout it undoubtedly much Icai prevalent in hot, 
than in temperate climates. Among the natives ill 
the interior of Afriea, we are told by Dr. Livingstone, 
that this diseftiie, as well as calculus, is onknown, and 
I am informed that gout is not prevalent in tho 
East Indies, except among European rctddcnts who 
have acquired it elsewhere ; the same remark applies 
to the natives of other tropical climates, for to Turkty, 
China, and Japan, the disease is scarcely known, and 
in Italy it is much less frequent than in France or 
Snghmd. 

It would, ncverthelos"!, be dangerous from these fiulft'j 
to draw the inference that this immunity is due to tfaAJ 
effect of climuti.-. fur the inhabitants of those wwrni 
countries are often free from many of the other predispoa- 
ing causes of gout ; for example, they .'cldom partake 
of ahsoholic liquore, and their food conteins less of 
nitrogen thtui that of nations in which gout is preva- 




ISFLFENCE OF SKASON. 



SOS 






^ 



lent We hare also proof that other oiroimuiBDeei 
influcnco the derclopmcnt of gout more than mere 
oluaate. in tho fact that in Itonii>, under the Ilepub- 
lioin form of gorcmmont, tho disorder was little 
\o9nif hut under tho Empire, when liisury and 
andolcnoc pntvailod, it became extremely common, 
eroQ iinon]; fomiilcs. Wc have already had occasion 
to nlttidc to tho circumstance of tho dijoiJ^ being rare 
anwcg ccrtttin other nutions, as the Scotch, Irish, 
Russians, and Poles ; but we found good reason to 
ascribe tho immunity which tho people of theee 
countries enjoy, rather to their abstaining from etrong 
wines and malt liquors, than to any o&bct peculiar to 
fheir dim n to. 

The influence of season in detormtning the lime of 
■n Bttack of gout, is often veil iihowD in tlio earlier 
■tagiw of tho dUordor, when the intervnls between the 
fita arc conHidemble. That the discoae u most apt to 
occur in the spring and autumn is a fact known from 
the earliest antiquity ; as Ifippocratcs rcmarlu; in one 
of his aphorisms, " Podagrici affootns Tens ct tutunino 
plt^mm^ue moTentur." Galen aim affirms that spring 
.u tlio »eamn when the return of gout is to ho expected, 
Sydenham conadered that about tlio end of 
Xanuar^-, or hcg inn ip g of Februaiy, the diwaso u«ually 
bre»k.H out. 

The examination <^ a lai^ number of gouty 
patients with reference to the time of year at which 
the first attack of the diwaso manifested itself, has 
fiilly satisfied mo that tho optaioDof diestieienti a 



»0 



CAUSES OF ooirr. 



OOROct. I have usaally found tbnt not only the first, 
but several of the curly iittacli^ for the most purt of 
omiiiiil occurreaci', take ploco in the iipriDg ; aft«r ft'^ 
time un uutumuul fit is luldcd, but when the discaso ' 
has bfcomo oiigraft«I into the system, tho returns may 
l>u mora frequent and Eit Ic^ regular iiiUTvab. 

Ab s rule, even thoso who suffer from Uio more 
daomc forms of gout, are comparatively free during 
the hot months of summer, though oocosioually veil 
marked exceptions are found, and I have seen patients 
who suffer even more in summer than at any other 
time of the year. 



Infiuence of Lead as a predkpositif} cause of OouL^ 
It is a vcU-established fact that metallic impregnation 
is capable of inducing pains iu the extremities which 
bear a close rcsembknco to those of rheomatism; 
artiiicers exposed to mercurial vapours often suffer 
from what is termed "neuralgia mercurialis," and 
plumbera and paint«ra arc afflicted with somewhat 
simdar pains, which liave bcun deslguuted " lead 
artliralgia, or metullio rheumatism" by Saavagce. 
The peculiarities of the latter affection consist iu tho 
pain being severe, and following to some extent tho 
direction of tho large nerves, and not being accom- 
panied mth tenderness, redness, or swelling. 

The relation between lead impregnation and gout 
was not, I believe, made publicly known before 1854, 
when, in a paper read before tho Medieo-Ohirui^cal 
Society, and afterwards published in tho Tnuisac- 



IHFLUKKCB OF 



n 



I 



tioDS,* I aUudMl to Qui cunou» ftict that u vor>' large 
paropottioD, at loitst one in four, of the gouty patients 
who had oomo under my caro in Univcrsitj' College 
Hospital, had at some pi-riod of their lives boea 
affected tvith Ivftd poifoniug. nnd fur the most part 
fijllonrcd tho oceupution of plurobcrs and painters. 
Snoe that datv I havo kept tlio subj<.'<l promioeDtty 
before my mind, and subscquout cxporicncu ha^ fully 
ooofirmcd the coTroctnoi<s of my origitiul Htatcmcnt. 
I hare also DfOLTtuinod. from rvpL-utciI inquiries of the 
miustorx oiid invii i-iigiigi^d in tbc uluvc trades, that 
goat is much inorD provnivnt among painters than 
other workmen earning similar wages. Thcro appears 
to ho nothing iu tho Iiuhits of thc»c men to account 
for their peculiar liability to gout, with the oxccptitni 
of thdr exposure to thu influcneo of lead. Dr. Bur- 
ruwes, &om his expcrienee iit St. Bartholomew's, i» 
oOBvinccd of Uic trutli of the above statement, and 
other pbynciaaa fauvo tcstilied to tlio Mime. 

On reference to my cosc-buoka I £nd that fifty-one 
male sabjecto of gout havo been under my care in tlic 
bospital since the publication of the communicatiou 
in the " Transoctioiu " above referred to ; of these as 
iBimy as sixteen Tcro pointers, plumbers, or workers 
in lead : these numbers do not inclode patients with 
lead poisoning admitted info the wards, many of 
whom had been affected with gout 

Some questions of tntenst in conneotioa with this 
subject immediately mggest tJiemsolres to the mind. 

* Vadko-CbirarcltBl TmuMtioMi raL ustl, bt ISf I. 



ars 



CAUSES OF OOCT. 



Can load imprcguniiun induce gout vithout tlio oo> 
oporfttirv aid of olhi-r prcdijiposin^ causes P Grant- 
ing the powerful influence of this cause, in wKut 
maoner docs it net in producing such result ? 

I am not prepared to answer the first quiwtion in 
tho uflirnititivc, but at pre-^ent should hesitate to 
assort that the metal cannot of itself (iL'caaionolly IwwJ 
to the development of gout. It would Ijo intere-tling, 
to ascertain whether in countrie* where gout is un- 
common amon^ tho working classes, na in France and 
Scotland, painters and plumbers are sufien-ra from the 
disease. Tauquerel dos Planches, in liis " Traits dos 
Haladics do Plomb," although he gives an account 
a great number of patients who sutferod from load- 
poisoning in its dilTcroiit varieties, does not itlludo to 
any of them having had gout. Through tho kinduoss 
of Dr. Ohristison I am enabled to give tho results of 
that gentleman's ^-nluablc cxpcricnoo. In answer to 
some inquiries in 18-59, Dr. Christison remarked as 
follows : " I am imiibic to supply you, from Edlnbui^h 
cxpcricuce, with any information relative to the _ 
question, whether gout ix apt to occur among thosB^^I 
who are liable to suffer from exposure to the dcloterioua 
influence of K-od. Poisoning from protracted exposure 
to lead 18 a very rare occurrence in Edinburgh. Wheo 
X first bccumo acqaainted wiUi the diseases of tho 
working classes bore, namely, in lftI7, aa clinical 
clerk, a few characteristic cases of lead-colio and palsy 
were annually admitted into tho infirmary from a 
whitelead manufactory carried on according to the 



ISFLUENCE or LEAD. 



S73 



oltl ppoeeas at PortobcUo, n villflgo Uirco miles off. 
la a few j-eara this source of supply wascd, in conso- 
qaeooe of the owner of tlio works adopting t!io method 
of separating the white lead fii>m th^ metallic plates, 
and subseqaently grinding it under water. 14'ot many 
ycars after that change, indeed, tlio luanufactwry was 
giTen up. Although I have been physician of the 
hospital from 1$'27 until two years ago, I hare 
Dot seen a Miigle cose of Icad-oolie or ordinary 
lead>paLiy during all Iho intervening period. I can 
recollect two caae-s of wrist-drop in compositors, that 
ia all. Among house-painters and plumbers, both of 
them numeroos here, aa they work oxtennvcly in 
the country around as well as in the city, 1 IinTO 
never encountered a single instance of lend disciiic in 
any of its forms. I remember making inquiries about 
tho effects of load from an intelligent house-paiotM*, 
vho irns my piitiint in the hospital for some other 
diseoBO; and it appeared that ho had never eren 
heard of workmen in his trade being liable to any 
diieow depending on expo^re to lead. It is so far iu 
aooordancc with your conclusions, that we know as 
little of gout, as of lead disease, among our hospital 
patients. Goat occurs very rarely. I have known but 

ro eases of it among my whole hospital service ; 

Dth were in fat, e\-idently over-fed butlers. I w«* 
ansiotifi to ascertain the cause of cxemptioa of oor 
puinterM and plumbers from lead disease, eq>edatly 
paint^Ts, who suffer from it ao much elsewhere — even ia 
London, for example. A journeyman, who hod beta 



Sit 



CAUSES OP COLT. 



ti housd-paintcr far seTenteea ycai«, a part of wliicli ho 
hftd Jipeot in IxindoD, waa veil acquaiuted wiUi Iead> 
Colic (uid Icnd-polsy, os occuiriiig nmongst liis follow- 
workjiicn in the capital. He assured me that neither 
he nor any painter of his aoquaiutuiicc in Scotland 
had c?cr known cither disease among paintci'S who had 
worked only in Edinburgh. Ho asoribod the diflcrcnce 
between London and Edinburgh to the circunstance, 
that in Edinburgh they are never so far from thoir 
homee as to be prevented from going thither for tlieir 
meals; tliat tliey tlierefore take off their workiug- 
dreas, or ovcmlU, and wash their hands and faces 
before gOLDg to meals ; but that in Loudon, workmen 
are so far from home or thcii' mitster's establishment, 
that thciy cannot go home for breakfast or dinner; 
that they thcrofoi-e toko their lacals where they work, 
and do not then take the trouble of changing tlicir 
dress before they feed. This appeared to bo a very 
feasible explanation of the difference, and various 
muster painters and joumej-men have since confirmed 
that Tooji's account." 

One cirouin$tanco, vhich appears to point to the 
OOOAluson that lead alone dues not very powerfiilly 
predispose to gr>ut, is the ftict Uiat women engaged 
in white-lead manufactori&t, and who often suffer 
from colic, nro not afflicted with gout in like ratio 
with men, but the influence of sex may possibly »• 
count fur this immunity. 

To ascertain tliu niauner in whicli lead acts, I have 
been hi to make several obs4.'rvat]ons and experi* 



^^^^^ INyLfENCE OF LEAD. ^^^^^^^^H 


^r^(^^> '*'^^ch appear to throw tiKht upon thf subject ; ^| 


^ these have consisted, first, in ascortaiDine. in serer&I ^H 


ioatanoes, the eonditioa of the blood and urinu of ^^| 


patienta under the influence of this mcta], and ^H 


KXMinilty in fli>liipmin>iif< thn ofTopt w)ii.>li tci.l hao ^^M 


upon the Bccrction of uric acid, when nclniinistviod ^^M 


1 medicinally. ^H 


^1 The results of the iuTcstieatlon ia twelve casc9 in ^^1 


^1 «li;i>). ttin liliui^ wna nvaminoil nra r.*I<ili;toi1 in tti« ^^ 


^H annexed Tabic ; — 


■ 


1 


OMal. 
J.8.. 

at. 44. 


Wrlatilmp. 
Uuhad 


WUhln tbt lul foar Illuoit iich In urio 
jrcftre bM wpaiBuoed, uiil. ATFragedul} 
wi«nl Hlight 4tlaoLi uentlou of urio aiild 
<J gmiL bj kklao}* - 4 '97 




Ctmi. 

Ataur. 
ib.S4. 


LwdMOtf. 


Slight thnatvniiig of 
but no ftltack. 


Blood eoauiMd uto 

OF id. Uodento 

ftiDOtiiit of nrio idA 

InorlM. 


ChM3. 
Li, 

labourer 

b.4X 


Lwdtolio. 


K*T*r lud e»at. 


A mudonto qoMtitjr 
ijtaitttid ia blood. 


ALM. 


Wild drop. 
UMhodlnJ 


NoTST bad gooL 


Ad aboonniJ mdooiiI 

(if uric tvrid la blmU. 


OMtK 

J. a, 

.AiMK. 

A. 41. 


WriMdrop 

uidlead 

eolie. 


No gout until lAcr 
MlmlMioa into 
tb* UoopiUl. 


f ' ■ ■ ^ — ^ 

Cn« aotd ftlmadiBt 
in Mood, lod my 
ilaficicnt in uriXk 


JBL94. 


LmmImHo. 


Bnerk^BPDl. 


No urio Mid ia Uo«4 
lAkoa ilarinf am- 


1 




J 



271 



CAl'SEB OF GOUT. 



J.O.. 

Lalwarct. 
Mi. se. 


Lead colic, 


K«>'er luul (Dut. 


No iit4a add Gnud 
isbloBd. 


CateS. 

J.C.. 

Fainter. 

jBt.«n. 


Ciilic mill 
wrist diDp. 


K«T<r liftd gout. 


Drie Mid in Uood. 


Cmc 0. a>lio and 
n. M-, wrutdtvp. 

P«In<«r. 1 
J,t. 51. 


Nertr lad soot. 


Much uric wnd iB 

blood. 


Cmo 10. 
W.P., 

St B5. 


Wrlil drop, 


Never had {ouL 


Dlvud I'icb iu ario 
acid. 


CkmII. ' Vrlit di'Op. 

J. n., 

QntfitUiT. 
Xt. -19. 


Kever bad goat. 


I'licMid iu u«od. 


Owe 19. 
W.B.. 
Hottl 
PoiMt. 


Writl ilrep. 


Ifrrcr iisd gaiil. 


Mnoh uda Hid in 

blood. 



From the abo\-c TftUo it will be observed, Uiat orift , 
scid i» nliiio»t invuriitbly present in tlio blood in casOS 
of lend poisoning, not only in tliose who have pre- 
viously sufii-red from gout, but even where nosymptoms 
<tf that diwa.«e hud ever shown themselves ; this fact 
is of mupJi iuipoi-tanw, inasmuch as, with this excep- 
tion, the presence of uric ncid in abnormal ijuantidcs, 
save in ea-sea of gout, is excessively rare. 

T Jiavc hud two Dpjwrtunities of examining the 
cflbcts of lead, when administered as a mcdimc. 



TXFLUEXCE OF LEAD. 



m 



upon the accretion of uric acid by the kidncj-s, and 
tbo rcb-ulto, altbatigh requiring much furtliLT con- 
fimiiktion, uro o<it without interest. The invcstiga- 
tioo t}( tho subj<M;t is beset with diJEoultic^, as tliu 
Ouce in which the salts of lend nro empiuycd aro not 
aomcrous, and it is ouly now nnd tlicii that tlio urino 
is capahti.' of being ooouratcly cttUected from such 
cuts. TliD first analysca wore made on — 
A man about thirty years of age, who had been 
pasidng for several days the following amounts of uric 
acid : 003 grains, 5-23 grains, 5'59 grain;!, 6'69 
graiiu, and 8-98 grains, the average for tho fivo day* 
being Q-aO grains. Atctato of load, in four grain 
doece, mado up into u pill, wus llioii tukiii three time^ 
ft doy, and tliu umountji of uric acid pus^ Uiu five 
following days were : 5*33 grains, 1*84 groins, 4'5S 
grains, 287 grains ; tho average bi-ing 3'G$ groios 
(tho rvault of Uie third (biy wa« lost by aoddont). 
Tho lead was only cuntinucd three dnj-S, OS soma 
nausea and sickness were induced. About a wock 
otter, a draught containing throe gruins of the load 
salt diwolrod in water, wiUi a few drops of dilute 
aoetio acid, was given three timi^ a day. During tho 
next seven dayt tlic amounts uf uric acid were : 3'07 
grains, 024 grain, &'08 grains, 0*23 groin, 2-95 
grains, 5'55 grains, and 103 grain.", averaging 2'Q(i 
groins During the next p<'riod of seven days tlio loud 
boing omitted and sumo idight tonic administered, the 
qnantity of uric acid eliminated each 24 hours wiu^ : 
7-40 grains, 6'21 grain*, 618 grains, 0-23 groins, <3l7 



S7S 



CACSE3 OP OOUT. 



grniiia, 8'58 grains, 12'G9 grains, tlie rtTcmgc being 
7*50 g^mnft. 

Tlic next pnticnt to ▼horn the drug wns ftdiiiini«t«rcd 
wits a yoiuig mun ubout 1!) yoars uf ago, who, for tbc 
nine proWotis days, piLsscd tho following nmouiita of 
uric acid : 768 gmiiis, 7-70 grains, 6*53 grainy 
6*60 graio!^, 8'64 gnuns, 6*24 grains. 6'8S groins, 
6'84 grniiiM, and 6"20 gruins, avDn^ng 6*76 grains. 
During the next ton dnys, when inking two grains 
of uci'liiU- of loud tliroc timfs n dtiy, tlip amount* 
of uric acid excreted were as follows : 474 grain-s 
1-92 grains, fl'63 gi-ains, 7-56 grains, 3*34 gniinB,7*80 
grains, C-07 grains, 0'27 grains, C'40 groins, and 6*51 
grains, averaging 5*93 grains. 

It will be seen from these obsprvnlions that in both 
patJGnts a wcll-marfeed diminution of the excreted nric 
acid occurred under fho influence of lead- In the first 
case it waa nmat marked, being more than one-half. In 
the second tho decrease was also cridcTit, though not so 
considerable. In both cosct, however, a very peculiar 
phenomenon was observed, namely, that after tbc 
drug had been given for a day or so, a sudden arrest 
of the excretion of uric add ensued, and the function 
of the kidneys became more or less intermittent, aa 
prcnonsly aacertainixl to bo the onso in potients 
labouring under gout. 

It would appear, therefore, that in individuals im- 
pregnated with lead the blood becomes loaded with 
lu-ic acid, not from tho inoreft-tcd formation of ih\n 
pnuciptci in tbe system, but from its imperfect exore- 



iirrLCEscT OP i-kaj. 



tn 



tion by the renal orgnns. Strang evidence has aho 
been ndilucod, eliomng thftt patients the subjects of 
leftd poisoDing arc, emfens pnribua, more liable to 
boeomc affected witli gout than otbere. 

I haw as yot Been no proof ttat other motalii 
poSMas ft similar prm'cr in diminishing; tho excre- 
tioB of uric neiit ; that some may, is not improbable ; 
tlterc arc, indeed, certain statements, which appear to 
ahow tbat lime exerts some influonee upon the de- 
velopment of goat. It was remarlced by Musgrave, 
that in IVvonshire gont became frequent among the 
inhabitants when chalk was freely employed in ngri- 
colhire, and phj-acians have made the ftaiiti obscrra- 
tion n-ith n>gnrd to the islnnd of Crete, and other 
oo»ntrie«, but at the sumo time it is not difficult to 
adduce strong evidence antagonistic to thii view. It 
is time them are ecrtain efaemioal characters common 
to lime and lead, and even some pbyinological and 
therapeutic resemblances may bo traced. 



Ercitiwj Cautn of Oout. — Several of the causes of 
gout which wc har« ronsidrred will, if at any time 
Snddonly increased in intenntj-, aot in immediately 
exciting a fit of the disease ; but there are otheni 
vhieh, although poteitt ns exciting, arc altogether 
povcTlca§ as predisposing causes. The amoiint of 
exciting cause ncccsmy to produce an atfaek depends 
greatly on the proneneas of the patient's syrtem to 
take on Routy action, fi»r w<> often see trivial irregula- 
rtties vhicb prodacc no iuoonvcnicnco in ono indi- 



sso 



CAUSES 07 OOUT. 



i^daal, readily cxoitc attacks of gout In another; nad 
it will alao bo found that causes which cxcito iiu altuck, 
unlike those which induce the disease, arc to a groat 
extent dependent upon conatitutaonal peculiarity ; thus, 
in one case exposure to cold, in another u fit of indi- 
gestiott, in a third some shock to the eysteni, will act 
as the exdting agent. 



Akokolic Sci'ci-affcs. — One most common exciting 
cause of an attack of gout U driukbg at any ono time 
an unusuatlj' largo amount of alcoliolio fluids, or the 
partaking, even in moderation, of certain wine*, us 
champagne, or malt liquors which have bocomo hard 
from acidity. So potent, indeed, is the Influeaco 
of special wines, that some patients cannot take u 
single glass of champagne without tho occurrence of a 
fit of gout as an almost immediate conse<jueuco ; in 
others, port wine acta more powerfully ; iu others, 
Madeira cannot be tolerated ; the cause of sooh differ- 
ences appear to depend on peculiarities of the digestive 
and assimilating fimctione. I have met with many 
instauces illustrating tho effects of tho above-named 
wincB, and likewise of strong ale. I lately saw a 
gentleman with his first attack of gout, evidently excited 
by taking an unusual amount of cccrcise, and drinking 
freely of beer. Cidor and perry will occaaonally act 
in a Bimilar manner. 

ScTcral instances shomng tho power of some of 
these alcoholic fluids in exciting gout have been 
related. One gentleman, disposed to gout, but norer 



ALCOnOMC DRIJIKS iS EXCITIKO CAUSES. 3S1 



Hnring cxpcneuccd nn attack in tbo summer scasoD, 
indaocd a fit by tutciiig lix or seven glasses of cham- 
pigno. Another v.as BCD«ibIo of gouty piuns iii Ills 
limbs before quitting tlio diiincr-tablc, from partuklng 
tbo SAiuo wine. A tliird brought oa u most 
Kvere fit by tndtilging for u short tiuio lii French 
vtoca. A fourth found his great toe hot, (lirobbing, 
stiff, and painful, w)>c-n he drank port wine, ercu 
sparingly, for a week. And lastly, in a patient, subject 
tr> gout in a very slight degree, pricking pains in the 
too immediately occurred after taking two glasses of 
port wine. 

These iustaucos might be multiplied almost iiideS* 
nitely, for evorj- physician who has had the opportunitj' 
of seeing much of this disease could relate eimmplcB 
fully oonHnning what has been stated. The know- 
ledge of the power of alcoholio stimulants in immedi- 
atdy exciting a gouty paroxyan, can occasionally he 
usefully employed in diagnosis ; and I bt'liuvu it may 
bo safely asserted, that irhai a/ev glmats of tcine, ate, 
or porter, guiclly imd incanably produce in any indici' 
duel an iujlaminatory aJMion ^ a Joint, ttirii iiijtam' 
wtation Uo/a Iriili/ gouty c^raettr. 

Djf^ptia is another powerful exciting cause of a 
gouty paroxysm, and not unfrequently we meet with 
patients who attribute their attacks to the use of 
certain articles of diet which have induced distorbauco 
of the digcetiro organs, and more espcunaUy to such 
as lead to the production nf acidity. OTcrioodtog 
the fitomadi with a roriety of luj^y-WMOocd and 



iH 



CAUSES OF aOUT. 



indigostible disliee, taking different vftrictics of aloo* 
IioUc beverages at one meal (moro injurious thnn tho 
some amount of any one kind), may be axm followed 
by ft gouty paroxj'sm. Teraporaiy congestion of the 
liver, lending to nu aKcration in the secretion and 
flow of bile, may also Ijc uttcndcd with like oonse- 
qiioncM. 

1 have seen a severe nttnck of gout, the result of 
Indigestion, cauecd by taldng a hot buth soon nft«r a 
flill meal ; and as sbon'ing tho*influcnco of aeida and 
indigestible ftrtielcs of food in exciting gouty sjinp- 
toms. Dr. Petit relates tho case of a Dr. Gupracnt, 
•whose joints, usually a little tender, became so trou- 
blcsomo after partaking of citron, as to prevent his 
walking. Another patient informed Dr. Petit, that 
he was certain to bring on an attack of gout by 
eating " dm pommes <iu beiirre," especially when tho 
fruit was unripe and acid; and the same author 
relates an instance of a gouty priest, who induced an 
attack of the disease twice in one year, the day after 
partaking of the dish called "du reaii A Voseitle;" 
and, lastly, Larry asserted that he had seen a man 
•who, whenever he drank lemonade, felt sharp pains in 
the joints of his lower extremities. 

Cold and moisture, although T believe absolutely, 
incapable of inducing a gouty diathesis, or of leading 
to the production of gout, will in many subjects act 
powerfiilly as exciting causes. J have attended several 
patients in whom this fact was well exemplified, cases 
in which there could be no possible doubt as to the 



. 



COU) AKD MOrSTL'RE AS EXCITING CAUSES. SSI 



real oature of the malndj-. Id one instance, a gentle- 
man in n-hom the iliiieaw commenced in the ball of 
the great toe, and always presented the oheracteristio 
phenomena of tnio gout, whose blood yras likewise 
{noTed to bo loaded with uric acid, the attacks were 
olwaj-H cxcit«d by easterly winds, and in no way con- 
nected with any appreciable disturbance of the etomach 
or bowels. The local a|li>lication of cold, even getting 
Utc fe«t wet, will often prove sufiliciout to excite a fit 
in gouty persons ; and among the lower classes &{s 
oanso in frequently operative, though not accompanied 
with indulgcnco in alcoholic liquors. 

WhoD oold acts as au exciting cause of gout, the 
effect u (Inc in part to its arresting the secretion of 
fln 6kin, and checking the escape of add ; at the 
ftune time it must be remembered that a ehill to the 
enrfaco la necessarily nccompanicd by congestion of 
tlie internal orgnns, lending to fiinctional derange- 
ment; cold may also oooaslonally act hy its direct 
sing influence upon the nervous Eyatem. 
\Ertreme mental or hodUif hhour, or dcprtxaon from 
other cause, is prone in some patients to induce a 
of gout Sitting up late at night, cspedally when 
combined with severe study, will often occasJon on 
attack. Van Swi<.-tcn rebitct tlio case of an eminent 
mjitbemnticiau, nho brought on a St by the long and 
eoaatant application of hi^ mind bi the nolution of • 
difficult problem ; and Sydenham, a.i before noticed, 
■Iwnys induced gout when devoting more than utatl 
nttcntioQ to the composition of bia TraeL Tiokmt 



m 



CAVSES OF OOfT. 



oxc^onuoi, as OD outburst of pa^on, will act in a 
nmil&r nuuiner. Grcot bodily f&tigao, as a long walk, 
is Bumotimcs foUuwed by n St, and the name may 
result from a severe bbw, fall, or other Injury ; many 
examples are on U'oord in which fractures of limbs^ 
di.^loctttions of jotntii, surgical openLtiuofif have bccQ 
followed hy an uttack of the disoose. Local injury 
not only acU in exciting gout, but frequently deter* 
mines tlic situatiun or locality of the inAumniation ; 
thuB, an iujury lo tlie knee or ankle will usuully cause 
these joints to be primarily affected, although the 
great toe or aomo other pai't may subBe^uently become 
implicated. 

Hemorrhage may act as the exciting cause, and tho 
offcct is then probably due to dcpi-cssion. I Itave eeen, 
for example, a first fit of gout produced by copiout 
hcmatemesis ; by losB of blood following tho cxtrocti 
of a tooth, by epiataxis and other foitns of heniorrhagCi 
On the other hand, it is not uncommon to find tho 
suppression of an ordinary discharge of blood, as tlu> 
sadden stoppage of the entamenia, immediately fol- 
lowed by a pftrox)flm. M. Duriuge relatt'S tho aac 
of a lady in whom tho cessation of the catumetiia, 
oausod by a violent fright, was followed by sove 
attaolu of gout, which ccasL'd when Uio patient ogoia^ 
became regular. C&aos illustrativo of the efiucts of 
the suppression of on habitual hemorrhoidal dischaige 
are by no means uncommon. 

The deproseion of the system caused by any other 
exhaustive disease will occaaonolly excite a fit of gou^ 



ecn, 

ioua^H 
tionH 
age.V 



iifl, 
of 1 



EXCITIKO CAUSES. SSS 

and sereral instances anaingfrom boils and carbuncles 
have oome under my notice. 

In concluding this branch of our subject I may 
remark, it would appear that all causes leading cither 
to an increased formation of acidity in tho ej-stem, or 
lis dcfcctiro elimination by the skin, and all causes 
saddcnly depressing neiroua energy, have a powerful 
influence in exciting an attack of gout in subjects 
already predisposed to it. 



JTATUltE OP GOUT. 



CHAPTER IX. 

Txtanwax oft Sjlivm w Ooct :— ktimkob or a cmsk KniTtra 
UTwEKx awt *x» mic aoio — chi-iuctku txn mitfttmim o* 
Clin 1C9D iiD m ULTS— rBObotrn or m XRisuWMat* 
CxDt* ptrrBiKirr iriitcuHnxxcM— m udcl'briixci i> nirm^n 
DUBKi or ttnuia—m ruitiOLomuiL im> rinictaMOifc 
knuMn— orinoK* or ma jmcinTa os tub xatcu o* mdt 
— nrLLu't ouMTion TO Tne no«T«>i or tiii iicworal 

rAIBOLOUI^TS, IXD HI* OKU VIXW* 0> TUS tCkJCOt — XUISaT 

lOMi^ TUKuKir — cMsioxi •>» itii c laucuMft*, sift. ■■ se^ 

UND, Dft. m>U)«. sn. UIIKUKIR. 1>D OTUKU— AtTlli>m'> 

own TlSiri ON TDK DITUXX OF ODUT — ■XPURJtMII Or tBI 

(ioiiiT I'uruuu A«e miuiuiiTOkT iriirTnug— iirLuunn 
or TQN rAKOxxiJi AUb (uuau» rnuoHtxA oosKtamt wim 
tni DOiui. 

IlAii»(i passed in rcrtev the plicDomooa ordmirily 
prcsi'itUHl by gouty subjoctis at least by tliosc labouring 
under tlio more typical forms of Uic disease l Iianng 
also asoortaincd tlio peculiar altcrutiuu of the blood 
and urine, and tlie morbid cbanges eihibitcd by tto 
difiercQt tissues utfcctcd by gouty inflammatioa ; 
and lastly, ha\'iiig studied the causes which aet most 
powerfully both iu predispoigug and e:xciting the 
malady, wc must now enter ajion a ver^' difficult 
inTcetigiitioQ, tlic detvrminution of tho truo uuturc or 
essence of gout. 

Fiom ft perusal of tho contcnU of the {Heecdiog 
chapters, moro csjK-ciuIIy each as relate to tho altered 



CHARACTERS OF ITIUC ACID. :«7 

ooEopoaitioQ of the Llood, oud the l'IicuucoI characters 
of llic oxtcninl <le]>ositi ocuurriug ld guuty patient^ 
uai o{ the matter infiltratcci in tli« tissues in and 
urouud thv ioiaUs, thu txtftdcr ciuitiot foil to have 
rcQUtrked, wliaterer may Imvo bccu his prvvious views 
of the pathology of the aSbotKiu, tlint a verj' mtinunto 
rclatioo exists between uric acid and the di»ea!« in 
queatioD ; such being the case, it vill bo advantageous 
to give a slight sketch of tlie nature and compocition 

I ()f this acid, and its relation to the orgooiflm in the 
difivrcnt classes of animals, and under the varying 

\ circttmstances of health and disease. 

^K Urio acid, or lithic acid,* as it is sometimes called, 

^^OOCtus, when perfectly pun-, in small white ^isteoiqg 
plates, consisting of duttvnod rliunibic ctyshds, BO fine 
aa to give it the appcaranoo, to tho naked oye, of 

tan amorphous powder; but whco examined by the 
iBienmcope, its crj'stalluao stniuturo is at once recog- 
aised, and the forms it assumes are depiotod in 
mate 5, Sg. 0, and Plato G, fig. 1. Whoa sepa- 
rated from the urine of sci^nts aiul birds, it is quite 
white ; but when procured fr»ni human urine, it has 

Susoally a yellowish or r«d tint, dcpoudiug on the great 
affinity pussossod by this acid fur colouring matters, 
and its power of carrying them down when prccipitatod 
fopm any coloured lluid. The aolubility of uric acid 



Ciie srid «M fint iIInoicnJ in urlouj «Bl«nIi uwl uiio* bj 
Bckale ia UrS ; !t «w «UtJ litlik m>J b; Uottmo, bat aftcrvuJ* 
I «rio Mid bj Pounrar, bjr wbich dcu|D«lteo U k ««muiiiilj 



iUS 



JIATCBE OF OOUT. 



in water ia extremely limited ; it requires, accor^g 
to Dr. Prout, as much aa 10,000 times its weight of 
cold water, and even 15,000 times, according to other 
obserrors; in boiling water it is more solable, dis- 
solving in about 1800 parte. jUthough possc^ang the 
chemical properties of an acid, its waterj" solution 
docs not give the reaction to litmus paper. Uric add 
is insoluble in alcohol or ether, somewhat more 
soluble in dilute hydrochloric acid than in water, 
and pretty freely soluble in strong sulphuric acid, 
from which it is again separated on dilution witll ' 
water. In many saline solutions uric acid dissolves 
readily, as, for example, in fluids containing alkalies 
and their carbonates, for urates of tliesc bases oro 
then fonncd, — salts more soluble than the acid itaclf. 
TJrio acid is also rendered more soluble by mean.s of 
the phosphate or bi-borate of soda; to the for- 
mer salt, which is naturally strongly alkaline, it is 
found to impart an acid reaction, a result arising 
from the formation of the urate of soda, and tho 
amultaneous production of the add bi-pbosphatc of 
soda. 

Tlie composition of uric acid may bo represented by 
the formula — 

HO, C, H K, 0,. or «i » l.tta»ic «fM hj C,o B. N. 0^ or 

the water in the latter formula being considered as 
baste, and capable of being replaced in whole or in 
part by a Rxed base, forming two classes of salts, one 
t«nQed neutral, the other acid or bi-salts. 



COMPOSITION OF DirFERETT URATES. 



2M 



^ 



The salts of uric arid which poaseaa most interest to 
tlio pbysiologiat auil pathologist arc represented in the 
Aooompanying Tubk'. tu which their composition and 
aolnbility are likewise appended. 

of lod. .... HO, N»0, C„ H, N. O.+HO. 
Sslnbl* Id kbool 134 p&rU of Inlliot; water ud IISO 
fuU oTMld vat«r, 00* Fabr. Tbia ull tiitt* in nriuo 
and gone; blood, u &l>o dopoaiud nitHii lbs timiM 
<if JEDUtr labjuU, Ci7<tiLlllKB in tix-iidnl pHimmtic 
seeilM^ fre(|a«itt; ntti&ling rroni a otntrc. 

'B^rnl* of uamooU .... HO, KU, 0, C,„ H, S, 0^ 
SomHiiDM «ilibi in hamiiD urEno and unury olenl^ 
knd birdi' ud HTpcDt*' nriDa. CrjattilliaM in n»dlM 
k&d raaadid miae^ with pnjeeliog (picolsL •olnl'U is 
kbont 1600 put* of waUr at to* Fihr., mora tolubU 
la hot vaUr. 

ftto of jKitiuh .... no, RO, 0,0 B, N. 0.. Solable 
la 700 |>irbi of calil wbUit, iiUiat SO* Pahr., and in 70 
ftrtt of boiliuj water. 
BImatc of limo . . . . QO, Ca O, 0„, H, K. 0,*9 DO. 
DinolTM la 003 iiorUufcutd irator. 

(K-mMofmagotua IIO. M^, C.^ H, H, 0, <^ DO. 

OiNolTta in about 140 [art* of boiUnj walcr, and in 
9TS0 part* of cold waler. CiritalliHa In Doodle*. 

[■■UKto of Utbla .... HO, U 0, C„ H, R, 0.. lla 
•olobilit; U iBOcb gnabr tlian uij otiiri linowo anu, 
bvt bat Dot aa jti bno aocimUly dotetiDiDed. It oij>- 
IlltiND in liag prinuatie ii««11m. 

The neutral urates of these bases, with the exception 
of those of aniinoniB and magnesia, can bo artificuUjr 
obtaioi^l. hnt, as tho)' arc decomposed and cooTertod 
ioto bi-oiutcs by the action of carbonic add, which 
Bbetrsds half the combined base, thejr cooaot taiat in 
the fluids of the animal body, and posseas eemiMntirely 
little physiological or pathological mtomt. 



190 



satobe of oodt. 



tJrio acid, when acted upon by oxidisiiig agents, U 
disntf grated, and the nature of somo of its dcooin> ' 
puaitions is of coniiiderablc interest ; thus, when boi]<^ 
in water with the puco-coloured oxide of lead, the jiro- 
ducts are urea, oxolio acid, and allantoin, the latter s 
principle contained in the allantoic fluid of the cow. 
Sacb a mot(Lmoq)h(iei£ ofton occurs in tbo animal 
ocffiiomy; WuIiUt, for example, found that when a 
solution of uric ucid wiis iujtcted into the veins of a dog, 
oxalic ncid uppeun-d in the uriuo; in urinary oalouli 
&om tho human subject alternate layers of urate of 
soda and oxaliitv of linio arc ufteu seen, and in the 
urino uf patients usually giving riiie to a deposit of 
urates, slight circumstances, as change of weather and 
differences of diet, will cause these salts to be suddenly 
replaced by a crystalline deposit of oxalate of lime. 

MTien uric add is submitted to the action of nitric 
acid, alloxan and alloxontino are formed, and with tho 
addition of ammonia, the beautifid colouring matter 
murexide can ho obtained, tbo production of which 
forme so valuable a test of the presence of tho acid. 
When uric acid is Kubjcctcd to the action of a high 
temperature, as during dry distillation, the products 
of ite decomposition arc urea, prussic acid, and car- 
bonate of ammonia ; and when decomposed by fu^aoa 
mth a caustic alkoh, cyanogen compounds arc likewise 
pioducod. 

Tbo pbj'MoIogical and pathological relations of uric 
acid, as far as they are at present known, may be 
thus shortly enumerated. It is a constituent of the 



PlIYSIOLOGT OF CHIC ACtD. 



3»l 



anno of the Iit^thy human iiubjoct, aiid tho daily 
aoMRint uxc'rut«d by the kidneyB may bo c^timutud ut 
i«boat riglit gruins. It U also contaiued iu the 
imcrcat tracct in hcuUhy blood. It has Itkcwi^ 
oa s]iown by Sdicrar to bo contained in tlto spleen. 
■tbo nrino of many uthcr animob it i^ a normal 
it, 8omctini<.<» existing iu small amounts, 
fonning tho chief ingrcdifot of the ex- 
It appears to cxi«t in minute proportions in 
|uri»o of tho gramimvurous niummulia, as the ox 
looTT, m asserted by Fownes, Sodukcr, und Briioke, 
nd tho calf, aoeording to Wohler; in the oaruivorotu 
nniolia it is usually present tu much greater quaiiti- 
I than iu gnuuinivorous, though less than in moo; 
I oOTTcct estimate of uric acid in these uumala is 
attended with mucli difiiculty, nnd whoa opportumtios 
^AoE making tlto examinations oocur, the nrino can 
^Moarcvly ho coosidervd to be in a natural state, oving 
^Plotlic iultueticoof conJiucmout. Uric aoid has been dis* 
oOVOTfid by different ubscrrerii, eepcdally by Htcrooymi 
And Vauquelin, to be a coustituont of the urino of the 
lion, tiger, leopard, panther, bear, hyena, wolf, and 
I d og ; but in tho pig's urine it has not yet been found. 
^H In the urinary accretions of birds, it is a very large 
^Hud constant constituent, fonniiig the principal ingre- 
^oient of the Ecmi-solid white substance which is seen to 
iavcet their excrements. When ohenuoally examined, 
this white matter is found to consist of urate of am- 
nuuua, or more striotljr speaking the acid or bi-onto^ 
ud under the mioroscopo is obfiorrcd to bo compoMd 

* a 



sn 



NATUBE OF GOUT. 



of minoto spWncal or onil inas~so.«, liAVing tTic i 
aoofi repreeootcd in 1'Iiito VI., %. 3 (b), a d 
taken from the urine of the pigeon : the same appear- 
anoo is cxhibitod by the uritic of all birdo, and the 
size of tho uiassos tipponrii from my observations to be 
very Ktmilar, 'whether derived from the kigest spedes 
of bird.i, an the oatiioh, or the smaller kinds, as the 
eanary. Tii«o oval masses are orj-stalline, depolarise 
lipht, exhibit lines radiating from a ccntrei vith 
froquent wcdgc-.ihapcd indentations. The renal 
aeoretion of reptiles and many of tho invertcbrata 
exhibits similar characters. I may remark that in 
birds the semi-solid nrine scema to contain little else 
than the urate of ammonia combined with water; DO 
trace of urea is ordinarily present, but it is asserted 
by Coindct to be a constituent of tlie excretion of car- 
nivorous bird.*. Ouano, which is tho excrement, or 
rather tho urine of sea birds, is usually rich in orio 
add. 

In the uriDe of rcpUU«, uric acid is an abtmdut^H 
jcgredieot; the uniio of the hoa coiistriotor Aa^^H 
python forming the chief source of tho uric acid of ] 
commerce. lu the ophidians, aa in the case of birds, 
almost tho whole mass of the urine condsta of ante 
of ammonia, no urea being present. 

The urine of most saurians is rich in urate of 
ammonia ; It has been found in the crocodile, lizard, 
and iguana. In the chctoniau reptiles, as the tortoise 
Bod the turtle, it is likewii>c present. 

The diiferent statements nhich hare been made in 






PHYSIOLOOy OF CEIC ACID. 



au 



^ 



refcrcaco to tlio urine of the tortoise are casUyexpIained. 
One obeen-cr, for cxanipk-, lias asserted it to be rich 
in urate of ammonia ; another, free from this salt ; 
the discrepancy evidently depends on the state of the 
animal in relation to food : when a (oi toisf has not 
taken nourishment for months, as in tlie early f^pring, 
tho urine is u&ually clear and rich in urea, but when 
Dourisbment is freely taken, the urine becomes creamy 
in oomiBtence, and contains, in addition to nrca and 
liippnric add, a large amount of urate of ammonia. 

In fish the composition of the urine has been 
little studied, but some obser^■ers have noticud the 
presence of uric acid ; probably it resembles that of 
the oholouian reptiles. 

In the invcrtobrutu the presence of nric acid is 
ncariy constant ; it has boon discovered in the silk- 
vorm, butterfly, and house-fly, also in the moth, 
caterpillar, gnuBhopper, cricket, common and Spanish 
beetle, and many species of Mctoii ; indeed it is pro- 
bable that the nitrogeuLwd cxcntiou of invcrtcbnito 
animnia is chiefly in the form of unite of ammonia. 

From the above tx niitrka it will be obson'od tbat the 
oocurreuoe of thi.s aci<I b very constant thnnighoot the 
onimul scries, although the proportion in which it is 
thrown out is liable to extreme variation, as it some- 
timoB forms the sole nitrogeniscd excretion, at other 
timw a mere indication of iti; prvsenco is all that con 
bo diitcovered. 

The amooiit of nric acid excreted by the human 
mljeot is subject to muoli alteration, aiiaJng not only 



3D4 



ITATintE OF GOUT. 



Arom the prc<ionci} of ducasc, but from circnmsteitcn | 
ID no way inooinpatiblc witli Uie fxistcnoe of pcifeot' 
health. It is e».4Cittial, huwevcr, that wc iJiould bear 
in mind that tlio indication afforded by the socrctiflu 
of this acid cannot always safely be talton as an iniex. 
of the quantity formed in the sj-stem, for the kidneys 
may loa' their power of eliminating it by the urine, 
even when it casts in abnormal proportions in the 
blood ; a foct proved beyond doubt in the preceding 
pages, and of much importance in the pathology uf 
gout 

Among the Gircumstanc&4 especially influencing the 
amount of uric acid, at least in the oviparous animals, 
may be mcntionod the chiiroctcr and amount of the 
food, tlio timo of ibi exhibition, and the perfection of 
its assimilation by tho digc-ttivp oi^aiut. That the 
iWmation of uric acid is much altered by the nature of , 
food is made evident by tho ri?«ult of some experiments ' 
made by Bonssingault, in n-hich ho ascertained that 
ducks fed wn'th different BubataiiccB excreted varying 
amounts of this acid in tho twcntj'-four hours. For 
example — 



Vli«n na toiij «w admuiutaTtd, tli« quaiititj 
Clirovn ant wm .... 

Wtien balli of oUtj mv» tAKAUA l)ia AmDnnt 
vmoIm 

UniJvr • diut cmniiting of fom 

Wb*n ousin wu girsn . . 

Uctn k crlatins ditt .... 

Ditld, in BooUioT trial , . . , 

TTodoi' u <iis( (ymilMisg of Clitino 

KOi. of dodi . . ... 



4-163 gnioa. 



4'1<8 
4-413 
l«-4 
IST'OS 
SOS -28 

iss-e 

»l-0 



PHYStOLOGy OF PRIC ACID. 



»s 



AlOioiigh Boiusingnult'ii results show that the uric 
acid is derived mainly from tlip ndministrntion of food. 
Ices than five gniins being excreted by these ammaU 
■when fasting or when sabstanocs containing either no 
nntrimvnt or non-nitrogt'iiiscd ingredients Trcro gi\'en, 
still wc ha\-o nbund&nt proof that animals living 
on a vegctntilo diet will eliminato a. considerable 
amount of uric acid. A tortoise feeding on lottucci; 
tlirows out semi-fluid iimtc of ammonia in conndcrablc 
UDOODts, doubtless derived from tlio iiitrogwiiscd priri- 
dpkR contained in the plants which these nnimol-t 
devour in great quantity. 

Ijehmaim'B trials on his own person lead to a sunilar 
result, but at the same time indicate that in the human 
subject the nature of the food influences the secretion 
of nrio add, murh li>v-« than that of the urea. This 
obKTVCr found that he passed in the twen^-fbor 
hours*: — 



On ft (trlrtlf i«gtUh1e diet . 


. IG'Spiini of aria aeiiL 


Ob » miud <l)(t 


. IT ., 


Oa a alrictl; uitnal cll«l 


- 31-6 „ 



It seems probable that if the diet is only outHcicot 

keep up the proper nutrition of the body, the 

Dunt of uric add woidd be, arttrit paribnt, the Mmc, 

fttevor the nature of tlio diet, ussuming howrcvcr 

that tho food id of a wholesome cbaiuctcr, tlie stomach 



* It wiS b* «U«TTtd that Ulinanu MortUd an UDoaat of nfe tM 
hr iWs tha arnaai w« fcart adopud ; t^U b* aeeouola to hj ilalli^ 
tWt W WM labmiriag nixlaT aoaaaaOMiBC oTtba paliii>in>i7 tinot. 



aas 



NATUnS OF QODT. 



in ft condition to digest it completely, and tho indivi- 
dual in tlie enjoymciit of perfect hvultli. 

Any drcumstnnco leading to imperfect digcitioD 
and as»iuilutiun, whether it depends on tho nature of 
tbo food, or tho conditiun of the assimilating organs, 
may nt once niter, not only the ubsolute formataon 
of uric acid, but likowiso its relation to tbo other 
solid iiigrodients. Lehmann, for example, found tlic 
ratio of uric acid to the urea in a normal condition 
was one to twentj'-eigbt or thirtj', and to the rest of 
tho solid matter of the ui-Ine as one to sixty; but in 
indigestion, tlio uric acid was to tlio urea as one to 
from twenty-three or twentj--Bix, and to tho rest of 
the eolids an one to from for^-one or fifty-two. 

Tlic rc'lntiou of the luic acid to food is also well 
shown by the expcrimonts of Dr. H. Beuco Jono« ; 
but these iudicntc rnthcr the iiiimcdiato effect of diet 
than its absolute influence, and fhow that during tho 
time the food is undergoing the process of digestion 
the amount of nric aciJ eliminated by the healthy 
subject 13 at its maximum. 

Stfore tnklnii fooil, tiiv atiat «u of >p. gntitj 1021, ud 
1000 giaini jicldcl O'OiS gnuna of uric oidd. 

After uiimkl fuoJ, llm urlut wu at up. gnrltj 1027, and 
lOOO grvnii jrivUvil 1 '0S2 gniai ofutio tdd. 

After rrcclnble food, niiuv Bp, gr. 103S, and 1000 snlni 
Tielded I'OIO gndoi of urit lai. 

It 18 a matter of extreme difficulty to dificover tho 
many caui<es which afl'ect the formation and secretion 
of uric acid, and before wo can hopo to tlirow much 



pmrsiOLOQY OP itbic acid. 



107 



further light upon the subject numyoew aud extended 
invcedgations ore required. 

It vas a»<uiiicd by Liebig that tlic function of 
rcspiratimi jioA^c^scd much iuBueucc, and iu proQf of 
this hypothesU the fact was brought forward that the 
oartuTorotu mammalia cxcrrtvd very littlo uric ococl, 
vhcreoB ophidiaa reptiles living on similar food, threw 
out ciiormoiLs quantities of the same acid. In the 
fonncr class of auimali) the respirator)* function ia 
activo, and consequently the amount of oxygen con- 
sumed is Tciy great, whcrenfi in the latter it b at an 
exceedingly low ebb. 

The chemical explanation of tliis supposod action of 
oigrgen was verj- simple, and accorded well witli the 
known influence of oxidising ogcnto in breaking up 
uric a^d into loss complex oi^gauic compoimda^ and 
eepoctally urea. 

Unfortunately for tia» Uwory, at fiwt right very 
kttroctiTC, many facta cm bo adduced which at onoo 
fiuyw its fitllac}' ; for wv have only to coniadcr the 
dianeter of the urinary toerotioD in birds and iiuecto 
to be oonvincod of ita utter inefficiency to explain the 
phsnomeaon. II10 urine of hitdst aud iiuccts chiefly 
oonnats of urate of ammonia, yet their respiratory 
fttnetioQ is extremely active, and the amount of oxygen 
which they consume, compared with the weight of 
their bodies, is perhaps greater than in any otlier das 
ef nfli fn^la- It may bo that, eatrrit parihttt, the 
•mount of oxygen consumed has somo relation to the 
exereted uric acid, but evrtaiuty under varying circom- 



« 



NATtntE OF ooirr. 



stuicett, and in different animals, the natare of tUx 
relation cunnot be domonifti'atcd. 

Id the investigiitioii of the amounts of nrio add 
secreted in different disooses, too many other disturb- 
iog cansos btsdde tbe mere alteration of the rcepiratoty 
itmotion mnnt be taken into account, to allow us at 
present to lay much Htr»H upon the results ; as a rulci 
in febrile and inflummiitory affections tlierc i» on aug- 
mentation of tliis printnple, and more eapeoinlly when 
the liver and sploon, or any organ connected with the 
portal circulation, arc implicated. 

The condition of thu cutaiioou8 fnnotiou Kas gemy 
rally been supposed to itfTt^ct the secretion of uric neid, 
an opiuion supported by the appearance of deposits of 
orates in the urine when a patient is under the inBucQM 
of a cold, 08 likewise by the frequent occurrence of 
urinary calculi, composed either of this ucid or its deri- 
vatives, in the efurtom counties of Enf;Iund, where the 
influence of the bleak north-east winds is keenly felt. 
Probably the function of tlie skin may possees some 
power in altering the formation of uric acid, but its chief 
influence is undoubtedly cxert«d in altcringits soluhility 
in the urine. Suppressed iierspirutian is immodtatcly 
followed by an increase of urinary acidity, and hence 
by the precipitation of the uric acid either in the form 
of urate of soda or in a free and crystalline state. 

Exercise probably influences the formation and 
excretion of uric acid, !nit its exact effect has not yet 
been clearly defined. Ijehmann found that when 
under avtire exertion, the ratio between the uric acid 



I 



VIEWS OF THK ANCIESTS. 



- an 



and urpa in liis own orinp bocamo much leesciwd; 
■whea ut rest, and under a fixed diet, it wa» oi otu! to 
ihnty-eiglit, but nftor considerable exercise tlie rfttio 
was fts low as one to seventy-soveii. Otlier observers, 
howerer, have found an iDcrcaso of uric acid pwduccd 
by exercLso ; the evidence on this head is tlicrdbre 
diaorepant. 

Earing given a i^suni^ nf the more importnnt 6uSb 
vhich hare been ost^ertainod concerning the formation 
snd excretion of urio add in the different cUL!«es of 
aaimals and under Tar\'ing circumstances in the human 
aobject, we are now in a position to consider more 
paittotUarly tlic numerou=i views which have been heW 
time to time of the nature of gout. We have 
ly hiid occasion to nb«irvo that the undent 
physicianfl were wnll acqnaintcd with most of its 
enomena, and they likewise speculated to tome 
at on the intimate nature of the disease, hut 
ignorant of tlie 4)eouliar changes in compodtioD 
1 structure which ensue in the fluids and tisuee, they 
, BO opportunity of arriving at its true pathology. 
The ancients were chiefly hunioralisfa, and con- 
adored gout to be produced by some morbid condition 
of the blood, but the nature of the alteration waa 
differently by Tarioua writera, some conaidor- 
ng it due to the presence of phlegm, others to bile, 
lud a third to a mixture of these fluids ; cbalk stonca 
looked upon by all as due to the exudatioa and 
tion of those impurities. The ideas oo this 
sbjact ODtcrtBtDod by several of the prindpol anoieot 



300 



yATTRE OF GOUT. 



authors, as Oalen, ^Vrottcus, Civlius Aurolianiu, 
jUexander, A«tlu», I'aulus iEgiucta, und Donictrias 
Paleologus, are EufGcicntly di;tui1cd in our introduc- 
tor)' chapter, as likewise Uio opinions Lcld by tlio 
ArabiaoH nod other ph)'siciaiis up to tlio luttcr balT of ' 
tho prcscut ceutury, including Avlceaua, Rhafiee^ 
Scrapinn, Iloflman, Coste, &o. 

In the ktter half of tlio last century, CuUea became 
the great opponent of the ancient humoral doctrine 
of gtiut, and, iu his work on the " Practice of 
Medicine," brought forward many arguments which 
(at the time they were propounded) wci'e of themselves 
powerful, and made still more so from the weight of 
his nuthorit)- : the substQnce of these argnmenlis which 
embody tlic chief objeotioiis made by Bubf>Gi|uent anti- 
huinoroliBts, may be tlius summed up : — In tlie Itrst 
place, he urges that there if* no evidence of any morbid 
matter being present in persona dispased to gout, and 
tliat there arc no experimcnbi or observations which 
show that the blood or eecretions of gouty subjects ore 
in any way different from those of other persons ; that 
previous to attacks of gout there are no signs of any 
morbid state of the fluids, and the disease generally 
attacks those who usually enjoy the most perfect 
health, and who even appear to be so when the 
disease comes on. Oullen allows, however, that at 
certain periods of the disorder, a peculiar matter 
qipears in gouty patients, but that this occurs only 
in a few instances, and only after the disease has 
subsisted a long time, and he looks upon such ao 



CVLLEtT'S VIEWS. 



901 



occurrcnco m tbo effect and not the cause of tlic 
taalady. Furthermore, altliough he t^ays ihnt thorc 
sro certain (icrid Rubstanceii which vhcn takcu .oecm 
to cxcito gnut, yet he considers that they do uot 
opera^ bj- affording the material eaiise of it, but in 
aomo incxplicnblo tnanner. 

From tlicso considerations, Cullcii concludes that 
tfacrc ia no proof of any morbid matter being the cause 
of gout 

In the second place, he looks upon flie suppositiAnA 
oonocming the particular nature of the morbid matter 
as too Tague and contradiotor^-, and many of them 
too incooaist^nt with ohemical philosophy and the 
laws of the animal economy, to allow us to conclude 

I that any such principle exists. 
Thirdly, he eonsidors that the idea of a morbid 
n>tter being the cause of gout is not canRistcDt witli 
{he phenomena of tho disease, particularly witli its 
frequent and sudden transUtion from one part to 
another. 
Fourtlily, he argues that if any morbid matter dooi 
exist, its operution should be flimilar in the sovrral 
parts which it attacks ; whereas it seems to be differ- 
ent, osciting inftammatioii in the jointly but aeting as 
a acdatiTe and dc«itroying tone In tho stinnaob. 
1^ Fifthly, he l<>oka ujton tlic diacoao being non- 
^B oontagiou.1, as favouring tlie idea of its being us- 
^M oonnectcd with the pre-xencc of a peccant matter in 
^^ the syntem. In explanation of this remark, it must 
ho rcmemborcd that, prior to Cullen'a time, there 



303 



XATURE OF OOLT. 



tvcro msny who thought gout contogiouSi utd 
uistiuicc-j £ttppo(^u(I tu fuvoui' suoli view* uro to bo 
foimd in niuny old authors, its BoorhauTO, Vun Swiiy 
tea, and others. 

Sixthly, he thinkH thut tho fad of tho discBso bciti^ 
heroditary is uo proof of ib humurid origin, for hu 
argu(»i that most hervditury di»(.^aei.'ji do not dcpcod 
upon thv pn.'i>oiicu of uny morbid mutttr, but upon a 
jiurtiuidiiF confurmation of tho body, transmitted from 
thu purout to tho oS^priiig ; and this ho suys applies 
jiiirticulurly to goat. IIo also aeserts that heroditary 
diseuecs depending on a inorhid poi«uu, alwayit appear 
earlier in life than is usual with gout 

SeTCOthly, he states that the humoral view of the 
disease has hitherto not suggeetcd any soccessM 
method of cure, but has sometimes led to iDJuhous 
trcotmcDt. 

!Eighthly, he regards the idea of the presaico of a 
morbid matter as altogether useless ; tliat it explains 
nothing, without supposing that it produces a change 
in what he terms the moving powers ; while a chaugo 
in tho state of these powcis explains every (dicum- 
sta&oc without tho supposition of morbific mutter. 

Lnfitly, Cullen considers the view superfluuut^ 
tluuking that without such suppositioa the disease 
can bo explained iii a manner more consisteat with 
its phetioincna, with tlie laws of tho animal ceonoiay, 
luid with the method of euro whieh vxporicnco hu 
dictated. After having urged thi-^o numerous ohjoo- 
tiuos agaiuat the humoral pathologists, most of which 





C'lTLLlSrS VIEWS. 



803 



oaa bo shown to bo dvvoul of wdglit itt iho presvat 
tiiDC^ utd auuay absntutcly (-rniuooiu', CuUcn proccuds 
to CDUDciatc hu own view uf tho miturv ot guut^ u 
view which, in ii xoincwltat tiiotli£cJ fonn, baa found 
numerous su]]pork>i« up tti tho pment time. Arguing 
fn>m Uic- .stHtomcnt^, thnt mnHes are cspcciiLlly affocted 
with gout, and thut Utow of tho opponto eox who 
suffer from it uru aiually robust and of full liabit, that 
oonucbs un: seldom idHidcd with it, and that tho 
discodo iittiicks tx>hu9t nuii with lurgo hnuils, Cullcn 
orriTos at the a>nclu^iun timt gnul dvpi-nds on a pcca- 
Itar oonfonnution, und more OHpcdally on lui nffection of 
tho ncrroui} centres, in which he think.-) the primiir>- 
monng powora of tho wliolo system aro lodged. Ho 
looka upon the exciting cum& of the disease as iutcm- 
peniKc, indigestion, dcpresnng influences, and cold. 
u acting dirvctly u|)un the nervous system, and con- 
aidsra most of tho symptoms of retrooedent gout, 
to be oflorwards dctcribod, as manifestly offoctioiis 
Fof tlio same kind. He also considers lb6 stomach, an 
oq;an ao universally symputliLfing with tbo rest of 
tbe body, as must freqneoiUy and most ooDsidorably 
implicated in gout; on opinion ho deduces from tbo 
laot tliat sj-mptoms of dyspcpeda generally pivoodo 
aa attack, ainl many of the excitii^ oauies of a 
.porozynn act first upon tbe stomach, and tltnt in 
ctioccdent fonos of the dismao thia organ is commonly 
lectcd. lie also thinks a balance exists between tho 
' of the internal and cxtomal parts, and that iho 
jtion of the stomach ts intimately coonootod with 



I 



I 



SOI 



NATUBB OP OODT. 



titc latter, so tbat tlie state of tojie in the one may 
bo comniuDioatcd to tlio other. 

Prom these promittt, OuUen fbrma Itic ricv of the 
pathology of gout, which is thus expressed in his own 
words ;— 

" In eomo pcrwns tbri-o is a certain vigorous and 
plothorio state of tho system which, at u ccrttun period 
of liib, is liable to u lo»s of toTio in the extromitics. 
This is ia some measure communicated to tho wholo 
Kystom, but appears more cs}tc>ct!illy in the functions of 
the stomach. When this loss of tone occurs, whilo 
the energy of the brain still rctaiiis its %-igoiir, tho n> 
mfdicatrix tialune is excited to restore the tone of the 
parts: iind ucciunplishea it by exciting an inflammatory 
affection in mnw part* of the extremities. When this 
has subsisted for some days, the tone of the extremities 
and of the whole eystem is restored, and the patient 
returns to his ordinary gtate of health. 

" This is the course of things in the ordinary form 
of the disease, which we name the ivgu/nr goal ; but 
there aro circumstances of the body in which this 
course is interrni)tcd or varied. Thus, when tho atony 
has token place, if tho reaction do not euccccd, the 
atony continues iu the stomach, or perhaps in other 
internal parts, nnd produces that stutc which we have, 
for reasons now obvious, named atonic govt. 



" A second cose of variation in the course of tho gout 
is, when, to tlio atony, tho reaction and infliunmatioQ 



cmxEyfl VIEWS. 



K§ 



tan to a certain degree suocoeded, bat, from cansw 
eitiier intcraal or external, the toDC of tho oxtrccaide^ 
luul porhnps of the whole sj-stom, is vcakcncd ; to that 
the in&aDiinutor)- state, before it had cither proceeded 
to Uio degree, or contiQUod for the time, requisite for 
nBtoting the tone of the sj'stoin, suddenly and entin-lj- 
OMses. Hvnce the stomuch, and other intcnial parts 
ralapeo into tho Htatc of atony ; and perhaps have thia 
increased by tho atony coniiiiunicati.'d from tho cxbe- 
Buties : all wliieh appears in what wo haro tormed 
rthveedeul gout. 

" A third coiw of \-ariatton from the ordinary cooreo 
of goat is wheu, to the atony usually preceding, an 
inflammatory re-uction fully «uocecd«, but its luual 
detdrminatioa to the joints by some cironmstanoes pro- 
rentod ; aud is, therefore, directed to an internal part, 
vhero it producer nn inflamiontory affection, and that 
state of things which wc hnro named the mitplact-d 
goet." 

Mo«t of the dc]gnia<i ontnidatcd by Cullen aro 
capable of being entirely di-iprovod at the present day, 
for it can be shown that a morbid matter is constanU;/ 
prosont in all ca^fcs of true gout, not only during tho 
inihimmatory stage, but orcn before the occurreneo of 
tho attack, and oonsoqucntly the first statement of 
OullcQ ill complettdy erroneous. Again, tho very 
nature of tho morbid matter con now be accurately 
dofiikod, and it« oompodtioB dearly demonstrated. The 
olijoetion that the phooomena of the disoaiw ore not 
MBwtcnt with tho euppontion of their bcinj; caused 



SOB 



SATUBE OK COOT. 



by the presence of n morbid mattor> has likewise littlo 
weight, for wo Imow tliut certain poiaona select 
particular parts of tlic octin»my upon wbidi to cxoitJ 
their force. Atropine, for exampin, peculiarly affeotaj 
the pupil of the eye, as well na the mouth, throat J 
nnd skin ; strychnia acts upon the .-tpinal cord ; thoJ 
poisons of Tarioiis cruptivo fevers also make particulnr 
Solootions, — that of scarlatina implicating the throat; . 
akin, ftod kidneys, and that of rubeola the skin and 
mucous membranes. Tlic argument that in one part, 
at a joint, gout acts as a stimulant ; in another, as tlio 
stomach, as a sodatire ; can hare little or no weight 
with any one oonvcrsant with pathology, for iuflam- ' 
matory action is usually accompanied with diminution 
or doetruction of tho proper functions of tbo organ 
affected. 

The fact of gout not being contagious would at 
preisent bo considered no proof that the phenomena 
it displays arc incapable of being produced by somo i 
morbid element in the blood, and therefore the fLflh 
objection of Cnllon falls to the ground ; and the nxth, 
founded on tho assumption that most hereditary 
diseases depend on a particular conformation of tho 
body, cannot have much weight, for wo know that 
many hereditniy affections are most indubitably pro- 
duced by tho presence of a specific poison in the 
economy. 

Tho three remaining objeetiona nc«d scarcely occupy 
our attention ; tho fact of a humoral view of tho 
pathology of gout not having ted to an improvement 



I 



VIBVS or UUKRAY FORBES. 



507 



in its treatment, miglit with equal justice bo urged 
against the viewa of the solidist; and mo^t pntho- 
logiatfl of the present dsy must feel the want of Mine 
more satisfactory explanation of the phenomena of 
tho disease than that afforded by CuUen or any of hig 
followers. 

In 1793, a small work was published by Mr. 
Muiray Forbes, entitled " A Treutiso upon Gravel 
and Qont," wbidi is remarkable for containing riowa 
on tho chemical nature of thetio diseases, not unlilco 
those entertained by some modem pathologiats. Mr. 
Forbes, for example, asserts that hlhic (oric) add, 
as it exists in the urine, must be prosi>nt iu tho 
blood, although he confesses his inubtlity to diMovcr 
it. His words arc, " its fioqucut deposition iu differ^ 
ent parts of the body a&bnh) indioputable testimony 
of its being contained in the gcuerol fluids;" tnd U 
this deposition uccuis iu eoitain circumstances, and 
more especially iu gout, ho makes the inqtury whether 
that disease may not ariAO in consoquencc of tbo 
ooncroting mutter being redundant, or whether tho 
coincidenco is merely uecidoDtaJ. Mr. Forbes goes 
on to show tho connoctioD botwoen gout and gravel, 
■i ozhibited in Uie similarity of the constitatiens in 
which they occur, and tho remedies best suited for the 
two disooscc, oomporiiig tho dqxwitioiu ia the tendi- 
nous struotniea to tbo formatioo and nparation of 
gravel from tho utiao. It should be bono in mind 
that this view was entertained before tho disoovery of 
tho real compositiou of gouly deposit^ by Br. Wolbs* 

13 



SD8 



NATUKE OF GOCT. 




toil, ill 1797, which accounU for tho error in 
Uial tlicy contaiiicd hca uric acid und not luate 
sods, and of tho prt-cipitation ur diposition being 
Oscnbcd 1« the liberation of tho uriu ii<;id by tiic aid of 
anothor acid introduced into th« economy. Tliij 
theory, idt)ioug]i someM-hat enoncou*, approacltc 
closoly to tlic truth ; and, conGidLTiiig the tiuic it vas 
promulgated, is cliaractenBcd by great por»])icuity, 
was the (ii-st to give real im|H>rtanco to tLu liutnoml ' 
dootriuo of the disease. 

IfotwiUistandiDg the arguments brought fonvard by 
Sturrny Forbes, and tho increased weight given to 
ihcm by tho subsequent discovery of "Wollaston, tho 
doctrines of Cullen continued to bold sway, at least in 
a modified form, and the late Sir C. Scudamorc, up to 
the time of tlic publication of Uic second edition of tho 
Appendix to his work on Oout, was uiclincd to faroor 
the \-iew which attributes tlie disease to a »peciea of 
plethora, rather tlian to any alteration lu tlic compo-f 
aitiou of the fluids ; still lie confessed to many diffi- 
culties in explaining tho rarioua phenomena of gonfcl 
Da euch a h)-pothe»3, and more cspooinlly the 00- 
currCQCC of chalk-stones, which he allowed wera noror 
seen except iu cases of true gout ; but he thought 
these deposits so riiic, that their presence eould not 
be employed us a baas for the construction of a 
general Uieory of the discaso, and much less could tho 
matters composing them be looked upon as its proxi- 
muto cause. As I'egards their rarity, bo remarked ho 
had only found tbcm forty-five Umi-s iu five hundred 



VIEWS OF SIR C. SCTDAMORE. 



MO 



■DBMS of gout, and in twveral of tiiese cases many 
I had clupstd U-foro any trace of such concretions 
Faumifvetod thomsolvta. Sir C. Scudamoro tltooght 
fliat 90 large a (ii'oportioa of persona could not pass 
through life under the m3rt}Tdoni of the disea»i\ 
KtDBuung wholly free from all nridence of the con> 
cretions, if any c»;cutlal rclatioii existed between uric 
uci<l and gout. lie likewise considered Unit wo hnd 
no proof of the exiatenco of uric acid in the system 
lodcpondcnt of sccri'tion, and that, even if it were 
prceent, Uiere mm no ap])nri'nt cause why it #hould not 
■lwaj'8 be wcreUd by the kidneys ; he was of opinion 
that in the cases where it was thrown on the joints or 
othor distant parts, the capillary tc8so1s of the stnic> 
turca affected n-ith gouty infla-mmation acted, in a 
gifiator or less degree, vicariously to tlie secreting 
TOKcLi of the kidneys : he aUo stated that in several 
MH« of extenxive depofita in the hoiidH and feet, he 
luid by repeated exptriments found a defioicncj", and 
eomctiioes almost total absence, of uric acid ia tho 
nrino. 

At the lime Uib opinion wws promulgated (hero 
ma uo proof of the production of uric acid id tho 
Cfltcm independent of scorction, and the coMt/ani 
pnsenco of urate deposits in tho structures affected 
-viA goaty inflummatioD was likewise unknown, 
naving attended Sir Charlos profiwaomdly in tho 
latter yoars of his life, I have roason to know that his 
ojiinioa on tho proximate caoro of gout became much 
altered, and he was inclined to look opoo tho disease 



Ilfl 



NATPBE OF oorr. 



as intiiriBtcly cotmeoted TriUi the abnormal presenoe 
urifi Bcid in th« syMeni. 

Dr. Dnriow, in nu ortido U) tho C^rdofMBdia 
Pnurtjcnl Ihl«<]icii>e, also eopport* tho now of 
bang olosolj- oonnoctcd with mfcular plotbon, 
•tato that a paroxysm of guut can bo regarded 
08 • ooiutitutioRal di^turbaitoo of nn inflamm: 
character, attended with local infianunation of a peci 
liar Idnd in ono or more joints, nuining a dct^nrninato 
ooureo, and in tho earlier oocasions tormiuatiog in 
K«<ilth, far tho moAt pnrt within a few days. Beoent^, 
howcrer, in his Manual of Practical Medioiao, the 
author apprare to have considerably altorrd his 
opinioiu »n the pathology of g<ont> aad now incUoo* 
to n modified humoral doctrine. 

Dr. Gurdner, a few years ranoe, advanced 
liTpodieBS in some rcspcots rc-tembling thnse 
enumnatod ; bo belicrcs that a general &tat« of 
cular plethora of tho groat chybpoiotic organs ta 
always met with in gout, as also tho constant prrsooce 
of a vaiicoso state of reins of tlie lower oxinsnitios 
during an impending fit ; that tho heart is oppmied 
vifli a flood of returning ronous blood, associated 
with nn impure condition of this fluid from tho non* 
oliroinntian of urea and urnteii, and probably of biliai; 
oonstitucnts. Ho however ndranoce a stop furtbsr 
fluiD the autliors before quoted, and thus dosoribM 
his idea of tho pathology of tlio gouty seizure : 

" Yonous cnngcatton I condidcr the first condition 
cawntia] to tho fonnation of tho gonty diathena. It 



i:ed ^H 

rti 




^ 



is nonowobw-rretion; it is found iiitcrsporsod tlirougli 
the writings of all funocr authors. Even tltosc who 
Adopt expknatioiLi iiicoosi-stbut with such n state of 
flitDgs, not^nthstondiiig admit it This sUitc bf the 
blood was first olcurly cnouncc^l ta the great caiuo of 
g«ut by Galen, whose opitiioos have continued to 

» influence tho mioda of succeeding physioions in a 
greater or lees degree, to tho prescut day. Tlic Lrutli 
of the fact lieing, I imn^e, unquestionable, it will 
abn^ oontimie to arabuTua tlw doctrines of those 
i/ba adTMaie oiHaioos with lAdA it is incompatible. 
But the great tchous codhIs of the body, as well as 
tho larger arterial vessels, aro endowed with a resi- 
licoqjr, which enables them to struggle well againrf 
de flood of returning blood. Thia fiuid, then, is com- 
prowed bctwvon two opposbg forces, that, namely, 
which is derived from the heart and arterial system, 
orging )t forward on its course ; and, on the other hand, 

»tbe antagoniBtic resistance of the great reins leading 
to the right auricle. Tnder this comprosdon I b^re 
that the vessels give way, and a true hemorrhage is 
occasioned in the part affected. If the rupture takes 
place in a minute capillary carr^Hng the serous portion 
of the blood only, cedema is the consequence ; but if 
the burst vessel be one carrj-ing rod blood, a true 
oechj-mosis is formed." 

I And again : " It will surdjr be admitted that the 
capillar)- and nutrient tcsscIb, distributed on the 
Mttrane and sentient fibnlla) of the nem^ are afieoted 
is tta mne manner as tho larger tommu tnuikt. 




312 



KATUM OF OODT. 



btliere tbese distended capilloiy vessels lie the real 
Mot and oauao of tlio pamful plicnomena of gcpat. Is 
it not crediblo that such tcsscIs, dilated so as to admit 
fluids for which they wore not intondpd, and bound 
down by the firm fascia?, in vhich gout haa its OBual 
eoat) may give rise to much suiforing ? " 

It will he no more difficult to refute tbeso riows of 
tlio nature of gout than the one advanced hy CuUcn. 
Lot us talcp, for example, Dr. Gairdnor's h^'potheas 
which is the most comprchenflivo of the three Kiid 
includes the rest, and examine it somewhat in detail 
Firat, as regards the general state of vascular plethora 
of the great chylopoietic organs, which he saj-a is 
always met with. In gout, especially if ac<iuirc<l and 
occurring in robust patients, a state of plcrthora of 
the abdominal organs is generally present before the 
attack, and thcro is then a fiibicss of the right hj-po- 
chondrium and epigastrium, sluggish bowels, dofccti^'o 
excretion of bile, and dyspepsia ; hut that thcso ^-mp- 
toms arc constant I much question, and can bring 
forward ri'curds of numerous catms in which there 
was no cridcDCO of nny congestion of the organs 
oonncoted wth the portal sj-stom ; snch absence is 
more commonly scon in spare subjects and in those 
who strouffly iuLorit the disease, and in whom wo 
shall find, as wo proceed further in our investigations, 
tho kidneys rather than the liver are de-fcctivo in 
their notion. 

On the other hand, if eongestion of the digcstire 
organs he intimately connected, and oveo a necessary 



VIEWS OF DB. GAlRDKER. 



SIS 



3cnt of the gouty parorygtn, how doos it happen 
QiAt in diaeoses in wliich thc^c organs bc-conio tondcd 
with blood, and in wliioh conj^ostion is so promincst 
a ftymptom, the sulferere nro not more frequently 
sfflivtcJ v,-ith riiutationD of gout f According to Dr. 
Gairdoer, f^uoh Hubjeets haro nil tlio neoesRary 
eloments for the production of the hemorrhage of the 
minute vcfiscb of the eKtremiltc!) ; niorcoTcr every 
serious diiiea.se of the heart, when that organ has 
become so defective in its action as to allow of con- 
gestion of the whole vtmous system, should, according 
to the above view, give rise to a paroxj-sm of goat. 
That this is seldom the case, uU medical oiporioaco 
will confirm. 

The veins leading from tho inflamcJ piirt certainly 
become turgid at the time of the fit/ond so coiistontly, 
that turgidity is one of tho pcL-aliar ohancteristict of 
goutj* inflammation, but I should doubt its occurrmioo 
during the impending stage of an attack, and bcliovo 
it to bo the effect of some prior mischief within the 
joint 

Next, OS to tho occurrence of hcmorrhogc in cvciy 
fit of gout, regarded by Dr. Gairdncr as the cause of 
tho local oficction, and which, ho thinks, will probably 

irtle the reader by its novelty (for It must be re- 
membered that Dr. Oairdner bcHcrc* that hcmorrliage 
will explain all the phenomena of gouty Lofiummft- 
taod, and that it is the true ratioHak), it may bo 
urged with fairness that the autlior brings forward 
uo proof of tho occnrrcitce of hemorrhage in any 



814 



KATUBE 07 GOUT. 



gouty fit, and henee it mtiy he presumed he has novor 
Bt^en the eochymosis alluded to ; and with regard to 
the colourless lieniorrhago or serous cxudatioii, this 
ocoum in numerous affections besiides gout, and oaa 
be readily accounted for without assuming the very, 
questionahli; existence of vaaa serosa. 

As the reader will porceiTC, by referring to the 
chapters on morbid anatomy, my available opportu- 
nities of oxamining part^ affected u-ith gout hare been 
very numerous, but I must confess never to haro aeca 
the sli{;btost proof of Dr. Gairdncr's assertion ; on the 
contrary, otlier appcarauces have invariably been 
observed which are completely pathognomonic of gouty 
infiammatiou. ' 

It space pcrmittod I might enter into the con* 
adoration of tbo opinions of many other pliyaictans 
vho have within the la^t ecntury written upoa gout, 
but it will suffice to da little moTD than enumerate 
the names of some of theec authors. In this country 
Drs. Parkmson, "WoUaston, and Sir E. Home, have 
advocated the doctrine of the humoral pathologist^ 
and conddcred that a dose relation existed between 
gout and the presence of uric acid in the blood. Others, 
however, as Drs. Parrj' and Sutton, looked upon the 
disease as cither dependent on some peculiarity of the 
circulating system, or as intimubL'ly connected with 
disorder of the digestive organs. 

On the Continent, especially in Frtnco, the views 
of the patholng)' of gout hold by the most eminent 
writers, ns Barthcz and Quilbcrt, bare been extremely 



4 




VAKIOUS OPINIOiraL «1S 

raguo J tlo former scarooly venturing upon any hypo> 
thesis, but contenting himself with regarding gout aa 
ddpendont on a peculiar disposition of the system, 
combined w-ith ivcaknesa of the afFeeted parts: the 
latter, explaining the phenomena hy the supposition 
that under the influence of certain cnuse^i which impair 
the functions of digestion, impede tlie action of tlie 
dan, and gire rise to a condition of plethora, a matter 
intended to be excreted \a retained, and the tjiuphatio 
sj-stcm thus becomes loaded with this, the matfriei 
mortn'. 

Other French pbj'sicians, as Crurcilhior and Dr. 0. 
Petit, look upon pout as intimately connected with 
the presence of uric acid in the s\-s(cm, and both 
authors, v-ho wrote prior to the actual proof of its 
vdstcnco in the blood, employ povorful arjpmionts ia 
support of tlieir opinions. 

Defore nflVring to the proftsnon my own views 
upon the nature of thb disease, I cannot rcfi«i& firam 
ftlluding to Uie conelusions arrived at by a physician 
who appean to have taken m deep and comprchonsive 
survey of all the data whicli hod been established at 
the time hu article was penned ; I refer to those of Sir 
Henry Holland, who in his Medical Notes and Reflec- 
tions devote* a chapter to the subject, well worthy of 
attentive perusal 

Having given a slight sketch of the different ideas 
of the proximale cauM or naturo of gout, which have 
been mtrrtAiocd I^th in ancient and modi-ni times by 
physicians whose opinions are most worthy of esteem. 



Sid 



KATyRE OP OOUT. 



ftnd having had occasiaD to point oat the fidkcieB oS 
moiij' of them, it now behoves nic to expound tho 
riews which, ironi a long and nttentivc considcratioa 
of the varied phenomena of the disease, I have naysolf 
arrived at, and tliii^ tank I will endeavour to perform 
in as succinct a manner a-i possible. 

In tho Mcdico-Giinirgicftl Transactions for 1848, 
I ventured to udvauet- tlio following guarded "piniou, 
derived from Kcvcral observations on the condition 
of thu blood and miuo in gout, rheomatisni, and 
albuminuria. "The results of these cxpcrimenfs on 
the condition of tho blood and urine, prove that 
uric acid i» not a product of the actiou of the kidue)*!, 
as frttiuciitly supposed, but is merely excreted frum 
the system by thojio organs. They also appear to 
indicate that tho excreting fuiictiun of the kidneys 
with regard to the $olid portion uf the urine, is nut a 
simple one, hut that ui'e;i and uric acid arc .sepnratcly 
climinat<.'d ; cdsu that one of tlic«o functions may bo 
impaired or destroyed, tlio other remaining entire. 
It appears oUo prnbiiblu that, as in ulbuminuria, tho 
urert'Cxcrelinrj function being chiefly iinimired, wo 
finil a vicarious discharge of urea in dropi^ieiil 
cfriisionii ; so, in gout, tho uric aetd'excnttRg functioa 
being defective, ehulk-like deposits arc produced, by a 
nmilar vicarious discharge of urate of soda. 

" Gout would thus appear at least partly to depend 
oa ft loss of power (temporary or permanent) of the 
Turie licid-«xcreting function of (ho kidneys ; the pro- 
monitor)- .*ymptums, und those also which constitate 



AmiOK'S V1EW8L 



il7 



flie paroxysm, arising from an cxcojs of tliis adi ia 
the bluod, and the effort to exjic! tlic materics worbi 
from tho system. Any undue fonnottoa of this com- 
pound would favuur the otxnuTcncG of the discoM ; 
and hfinco tlto connection hetn'ccn gout and uric 
ncid, gravfl nnd uilctdi ; and also the influence of 
higli living;, wini-, ijoi-ttr, want of oxcicise, Ac, in 
inducing it. 

" ^lia Lypotliceis also explains two facts, which hare 
hecn regarded as militating agaimt i(« humonU patho- 
logy, Qsincly, the hereditary uaturu <jf thv affection, 
Slid its frequent oc^urreDce in low states of tho 
sj'stem ; for we can understand that the peculiarity of 
the kidney, with referenco to the excretion of urio 
acid, uiny be tronimiiltcd, and liliewise, that when 
tho fiuiction in question is penniiuoDlty injured, it 
will not require un excessive formation of this acid to 
cause its accumulation in tho hlood." 

These news were made public fourteen years sinoC) 
and subsequent cliuicul uhH-rvutions have fully con* 
firmed their accuracy ; ulthouj^h by thcm»elrc6 insuiE- 
cicnt to explain all the phenomena of gout, still, by 
tlieir aid, in conjunction uith other more recent inres- 
ligations, I shall be able to gtvc a rational exposition 
of the disease. 

In order to render my \iews coQCute and explicit^ 
I shaU present them to tho reader in a series of pro- 
poatioDs ; 

^nt, in true gout, uric acid, in the form of urate 
of coda, is iavaiiaUy pre^^nt in the blood iu aboonaal 



315 SATCBE OP OOUT. 

quimtatics, both prior t» and at tho pcrigd of Uio 
seizure, and is essential to its proilaction ; but tHs 
add may oocoaonolly exUt largely ia tho oirciilatiDg 
fluid without the development of inflammatory ^-mp- 
toma, as, for example, in cases of lead poi;jomiig, and 
a few other instances, lis mere presence, there- 
fore, doea not explain the occurrence of tho goaty 
paroxysm. 

Secondly, the invcstigationB recently mode in tho 
morbid anatomy of gout, prove incoatcetably tbnt 
truo gouty inflammation ia always accompanied 
with a deposition of urate of soda in the inflamed 
part. 

Tkirdlij, tJic dL-posit i» crystalline and interstitial, 
and when once the cartilagus nnd ligamentous struc- 
tures become inflltnttod, such deposition remains for 
a lengthoikcd time, perhaps during life. 

Fourthly, the dcpositi-d urate of soda may bo looked 
upon 09 the cause, and not the effect, of the gouty 
ioflammation. 

Fi/tfilij, the iDllLtmmation which occurs in the gouty 
paroxysm tend.i to the destruction of tho urate of soda 
in the blood of the iuflmncd port, and conscquontly of 
the qrstem generally. 

Sixthly, the kidiieya tiro implicated in gout, pro- 
bably in its early, and certainly in its chronic stages, 
and the rcnnl a&cction, perhaps only functional at 
first, subsequently becomes structural; Uio urinary 
secretion is al^o altered in composition. 

8«tenthly, tho impure state of tho blood, arising 



k 



AXJTHOK« VIEWS. 



9I» 



ly fipom tho prowiicc of urate of Kodii, is tho 
pfTibablo cause of UiQ disturbcuioe which proccdos Uio 
aet£ur«, and of mauy of tlie aDos»loiia ^mptoms to 
whioh gouty subjects are Liable. 

Biyhthiff, the cau9e8 whioh prcdiq)oso to goat, 
independently of those connected with individtul 
peculiarity, arc either Huch a.i produce ao inocasod 
fbrmutioa of uno acid in the system, or wldch Icud to 
its retention in the blood. 

Ninthly, the causes exciting a gouty fit, arc thoso 
which induce a loas alkalino condition of tho blood, or 
which greatly augmenti for tho time, tho formation of 
uric acid, or sucli as temporarily check the eliminating 
power of tho kidneys. 

Teulhltj, in no dtseaise but tmo gout is there a 
dopontion of urate of eoda in the influmod tissues. 

With regard to the fact enumerated in thu/rsf of 
these propotiitioQS, namely, tliut tho hloud in gout 
always contains on abnormal quantity of uric acid 
daring tho attacks, sufficiimt cridencu has boon olnwdy 
afforded, inasmuch as it has been shown in Chapter 
IT., that in fortj'-serca patients suffering from tho 
diNa*^ tho blood oontaiucd much urio acid, and 
Buhscquently to tho fonnation of tho tabic, an 
examination of tho blood of at least a hundred other 
patients, has dcmonslratod the some trutli. That 
this impregnation ocoors prior to on attack, is wcU 
illostratod in tho annexed ciuo of lead paralj'sis, in 
which tho patient experienced his first fitof goat when 
in the htx^tal. 



320 



SATUEE OF GOVT. 



Caw 6, Fib. 15, 1859.— J. B., nged 41, an artist, 
engaged in painting both in water and oil colours. 
About ten ycani tnace fdt some symptoms arisbg 
(mm the absorption of lead, first in tho form of colic 
(Uid obstinate constipation, and afterwards in tbe 
wrists. These sjinptoms were reliered, and ho 
rtsiiined bis usual occupation. About three ycats 
ago be complctt'ly lost power over botb bis wriste, 
and had a, scvi-ro iittuck of colic; be Ibcn camo 
for tho first time under my care, and by Ircntment 
was so fur restored as to tnuble him apain to pursm 
bis avocutions. Six weeks ago, be bad a rftuni of 
the wrist-drop and colic, which have cuntinucd up to 
tbe present time. Tbcro is now an entire loss of 
power in both wrists, also considerable wasting of the 
extensor muscles of the fore-arms, and of the flexor 
muscles of tlio right thumb; severe twisting pain 
around tlie umbilicus, and oonstjpati'd bowels, loss of 
appetite, and weak pulse. A rciy distinct blue line 
is seen on the free edge of the gams, both of tho 
upper and lower jaw. 

A small untouut of blood, obtained on admission 
into tbc bo'^iiitttl, exhibited tbe following characters: 

Clot linn, and slightly buffed ; Korum, yellow, Imns- 
parent and alkiiiine. Sp. gr. 1027 at 60° Falir. By 
the thread experiment there was evidence of its con- 
taining; abundiiMcc of luic acid. 

Urine pale, free from deposits, and jnelding scarcely 
a trace of uric acid when acidulated. 

During his stay in tho hospital, this patient expc- 



AtTTlrORH VIEWS. 



M 



rimced & decided attack of gout, flmt in tho metatar$o* 
plui]Mi{p}al joiut of tbo loft groat too, and aftt<rwards 
in tJic Corresponding joint of the riRlit foot, 

Tiial iu wrtain instances the blood may contain an 
abnormul amount of uric acid witlioat the oocurrcnoo 
of goaty inS&nimutiou, i<ri(Ii-i)cc* bos been afforded in 
aomo oases of lood-poi soiling, and »tlicr» will bo utiudcd 
to subsequently. 

In tlie Chapters on the Ihlorbid Anatomy of Gout, 
I believe sufficient evidence will he found to convince 
any pathologist of tho truth of the kpwhiI projiosition ; 
for not only ha^t proof been afforded that a depoution 
of urate of soda occurs in the chnmic fonns of tb« 
disease, but even that the slightest amount of gouty 
inflammation is accompanied with a nmilar dupotit. 
Its presence has been discovered in a case in which 
oidy one Kmall joint had been oifKctcd, as iilso in a 
knee-joint> knon-u to have been bat once infjanivd, 
and that very slightly, and, since the publication of 
the Unt edition of the present work, in a caso whoro 
only one attack of gout bad at any time occurred. 
This fact I wisb to imprces forcibly on the mind^ of 
my readers, be«auM in tho constancy of sach dipod- 
tioo, Um the duo whiolt has long boon wanting: 
tho ooourrenoe of tho deposit is perfectly patbog* 
nomonio, and at onoe sepHrates gout from every 
other diaeaao whioli at first sight nuty appear allied 
to it 

To my third pmpontitm, little further need be 
addi-«l, as I linvr already stated that in very numeToua 



SS3 



NATPRE OK GOUT. 



instances I have foond tbo cartilaginous and Uga- 
mentous deposit distinctly cTjstalliuo, andjuidoubtcdly 
interstitial, and with respect to their long pcmstetioe^ 
when onco dopositcd, I can bring forward Mron^J 
evidonofi. In Case 15, Chapter vi, where only tlic 
bnll of one great too had been im{iIiciitoil, two ycaTCl 
had elapwd, still the deposit wa.4 dLscnrered ; lit Ic 
an equal time had ehipsod in Case 13, where the kneo 
hod been but once and very slin;htly intlamod, yet 
distinct evidence of the mischief reniFuned ; in Com 
IQ, in which only onu attack of gout hud ooctured, 
we have pi«of that after an interval of tbirtt-cn ycani 
tho cartilages «nd ligament'* («tiU reniaiii infiltrated' 
with tho crystalline urate of »odii. In tho majoritj' of 
COMA tho di-iKt^its prnbiilily ri'itiaiit during Hfi-. increas- 
ing moro and moi-c, at each suocooding fit of thej 

disMLSC. 

It is of the highest importance to cstabUsli thfl 
truth of the fuurfh {iruposition, nnmcly, thtit the 
deposited urate of soda must bo regarded rather 
tho cause than the effect of the gouty inflammution,^ 
inasmuch »i< it brars clo(>ely upon the pathology of 
tlio diAen.se, but there are at the wiTue time certain 
attendant difficulties in the inquirj'. There ore .icveral 
reasons which militate strongly againtit the sappoMtion 
of the deposit lioing the effect of tlie inflamniation ; 
for instance, when tissues little liable to take on in- 
flammatory action become infiltrated, bul sUght 
vascular disturbance is produced ; this is i:i<pcctally 
the case with the fibro-cartilago of the etu*; and. 



AUTHOR'S VJKW'S. 



an 



liougli we now nnd tbeo mcot witti ]ifttic»te owort' 
of tlie formation of th<>»e littlo nndul<«, w1m> ox- 
pflricDce, in fact, a, gouty tit iu tho enr, yot in 
tbe majority of casefi attention bs.t nevor been dirodttl 
to thfi port, DO slight htu liecn (lie inBitmniation 
CMised by the cffusioa. 

Another roo-soii, utrongly ogainrt ^ some snpposi. 
taoD, is th(- stiitciufut contained io the Ji/li proposition, 
to bo nov ooufiidorod, namvly. that Uiu inflanunalion 
of gout ttsaii to the di-iitntotion of tlic unite of soda 
in the bitjod of the ptirt. Tho proof of this ut to be 
Men, lint, i]i the dwt tliat the aeram eSaat'd by tho 
■{^>lieatioD of a blister to the inUomod part dues not 
exhibit ovidoooo of containing urio ai;id, when the 
blood of the ptiticnt and the bli^r serum from another 
portion not so inflamed readily showi it* pniMncD: 
and socondly, in tJiu puculiur situatitHis and manner 
in which thcw depositions oocur, scloctinj; for example 
structuro* pOMMwd of slight vascularity, ue curtiliige, 
fibro-cartilogo, Ugomcnt nnd tendtm, and tfao xurfisoo 
of ^oriol membranos and, even in thoso iuenm, 
keeping to nidi poftiam of tbom as are furtheat 
mmorod from tlie iiiflucace of Uood-vessela. Thtu 
the dej)o«it in urticulnr oartiluge. although completely 
interstitial, first takoa ptooo ut the fnte sarfacc, oimI 
very gradually travels inwards towordt the bono. The 
only markvd exceptions I have Been to this rule, have 
occurred in the patella, in which oocoaonally nodtdea 
of mate of soda are oWrvi'd at some dietoneo finun 
the articulating mrfiu».>, often clo«o upon Iho oflMmns 

« tt 



911 



NATCJKE OF GOUT. 



tissue ; but ve mast remember that tbo patella is a 
naamoid bone, and by no mcansvasculorin itestructurof ] 
this may probably account for tbc fact that CruvdHuc 
discovered dc]K}si(js which bo considered to ooneist 
urate uf 0udu, tivoii witliiii tbi.' piitclla it#i.-ir. 

Wc huvo lilccwiito iwon that on tbc Rurfaoc of bonoaj 
much ultLTcd by ({out, cspeciiJly tbo condyles of tliQ j 
fuinur, the deposit avoids tbe continuity of the va»cu- 
lar fringes of tbc synovial nu-rutirnne ; a fact Gret 
pointed out by Dr. W. lludd, and seen in the delinea> ' 
tion of tbe Icnee-joint, in Plate III., fig. 1. 

Lastly, tbc results of certain physiological experi> 
ments in which uric acid has been injcctc-d into the 
blood, as also tbc rcadiuoss with which it is dccuni posed 
out of the systoni, confirm the idea that contact with 
blood -vessels, more especially when in a stato of in- 
flammation, has a tendency to cause the dcstructioa uf 
uric acid. 

It would thus appear that the ^uty fit is, ia some 
extent, a salutarj' proooss, ridding; the s^'stein of much 
uric ucid wbicb iiiny huvc been accuniuliiting for a 
considerable time ; but we must likcwiw remenibcr 
that it is always attended witli a (wrtuiu amount of 
local mischief, which mny or may not prove of subse- 
quent inconvenience. 

The truth of the tixfh proposition has been fiilly 
demonstrated in Chapter vii, where it has been sbown 
that with very few exceptions, in suhjectw who bad in 
any dc^e suffered from gout, the kidneys were altered 
by tbe depusition of urate nf soda, botli at the ends of 



AOTHOE'S VIEWS. 



1$S 



^ 
^ 



the pyramids and in tlie direction of Uie tubuli uriiiiferi ; 
that in mauy imtancfs thrae organs w«re contracted ; 
and in almnst all, an appreciable change had ensued 
in tho cortical structure. It has been imagined long 
since that the kidneys are affected in gout ; Morgagni, 
fcr example, had an idea that wo should find a due to 
the di«caK(> in thu cunditiou of thvse parti, and many 
of tliv writers before quoted liaro looked upon tlio 
IddDdya r9 implicated in conjunction with tbc! other 
abdominal viMcra. 

The effect of gout in altering the renal secrotioo 
has likewii'e been fully proved, tJie orio acid excre- 
tory fiinctiou shown to be dcfcotire, and the urine 
itflolf of^on to contain a i^inall amount of albumen. 
The imperfection in the eliminating power of the 
kidneys is nonielimea the chief, if not tlie only cause of 
the impure condition of the blood ; for to demonstrate 
that an augmented formation of ario acid in the 
aysUim is not ncccAHarily accompanied with an excess 
in the blood, we need only refer to the caH> of birds, 
in which the whole of the nitrogen is metumorphoecd 
into nrio acid, and yot tlie blood remains pare. In 
proof of this I may mention, that in several instanoM 
I have examined the blood of the turkey, duck and 
pigeon, and hare always foond it quite free from an 
axoeaa of uric acid. 

The irrent/i proportion is difficult to prove, although 
atmcdt every physioian is aoctL'rtonicd to reoogniso » 
I nlation between particular B)-mptoms and the 
preMDoc of certain morbid matters in the blood. We 



SIK 



SATl'KR OF GOVT. 



bavo iibsolutu pntnf, dcriviHl botli from phynologioa&j 
un<l [KitliiiliiKiciil 'ibjcn'iiti^jii, Unit whon tJio arinai^j 
iwcrctioii is cum^lcti'ly tttuppt'd, most sorioua and cvoa ' 
iktal Kyin]>U)m!t «ti«uo; luid it is tiionforo rwmukblo 
to suppoRO, tliitt if one ur moro uf its coasUtiiuuts 
\te Ktainod in the blood, certain morbid pbeDomena 
wunld reGolt tht'ttitrom. Sume uf thmo eymptonu ut 
Ihc coae of goat may arise siiiiply from th« prannoe 
of the special imparity, othoni poeiiilily from aiLj 
att(^ni[it lit its deposition, and the consequent roacdon. 
I nhould bo inclined to regard tho dyspeptio symp* 
toDui wbiuli uRuolly preocde the gouty fit as due to the 
f»nn<!r, and many of the anomalous ani invgular 
fcirniA of tlio disease which we sliuU hereafter more 
fully oonnder, as dependent rntht-^r upon Uio latter 
oauM. 

The diseiuwion of the Hffklh propomtion is of much 
tiitereot and considerable importance, for if wti oua 
prove the truth of the statement that the prvdisposiog',^ 
oausca are of different kinds, one loading to thd 
inernoscd fortwifioit of the morbid matter, the othor 
to itB nfeHtioa in the blood, wc at oucc have a cluo to 
tho varioties of the discaw, popularly known u Ura 
rich, and the poor man's gout M it has boon ahuwa 
that tho inHammntion is invariably uocompaniod fay 
tho (tcpovition of urntfi of soda, which may be rogorded ' 
ii» it« cause, it is endent that any ciroumsttnce which 
fuvotint nil oocumulation of this salt in tho sxniteiiv ] 
arxl thcifby paves the way for its inliltrati^vn into 
ibo itrttcuUir tiasueih beoomcs a predisposing (^uufler 



AtITaoU'3 VIEWS. 



«t7 



whether thin arUe-n from it^ augmented form&tioii &nd 
the consequent overtaxing of the renal oif^nii.'s or 
whethcr the excreting power of the kidm-y* bo simply 
impoded in their Doroial function. It ujipoani pn»- 
bable, that in the majority of ca«es of gout, both 
causes are in operation ; but on the other hand it iji 
easy to conceive that either, if active, might lead to 
the production of the disease. In the former case th« 
affection would be typiotl of the rich maa's gout, in 
tlie hilter, uf the poor manit. 

In the HuilA propoKitiun we have a.<isiinied that the 
inSltratioQ of unitu of twda into the tissues may lako 
plnoo in two v«y$, either by its gri-ut aeoumulAtion in 
the Uood, or by that fluid being rendered loss capable 
of holding it in solution ; the fvnner oonditioa may \» 
caused by a temporary increase in the funnation of 
uric acid, as by aggiavatod dysiicpsia, from partaking 
of v«ry indigctttiblo articles of diet ; or by a suddco 
loM of the urio Bcid-ezcTetiiig power of the kiiloeyt 
from mental shocks, severe accidents, and so forth, all 
of which we k»»w to be very potent in exciting a fit 
of goat; the latter otHidition is likely to bo iiiduoed 
by partaking of acid li(iuon>, on piirticular kinds of 
wine, hard beer, and pioklcA, or by the suppressvd 
aetion of the akia oausiog defective elimination of the 
normal add scorrtion, and tbo oowM-quout diminution 
in the olkulinity of the blood. 

The serum, in which the orate of soda is dissolved, 
ia alkidine. and this reaction is caused in jmrt by 
phusphido of soda, in port by olkoliDo bicarboiuites. 



NATtlHR 0¥ UOUT. 

In no COM of tUsuasv — and my <^portunities have boon 
numi'Toui* — luivc I foond tliis fluid acid, and it ia pru- 
bulile Uiat such n state would be incumpatiUu wttli 
life; but there u often a tnsrked alteration in tltc 
dogrco of ita alkalinity, and in many ca.<«B of chrooie 
gi)ut it has shown a near approach to noatralitj'. Any 
ditnitiutiuD in tho alkaline state of the blood lessens 
its power of htdding urate of soda in solution, and 
hence pramotos it» dopoeitiai], especially in tissues in 
which tho K-ocdou is naturally lc« alkaline than in 
the blood. To illustrate thi* oxpcrimcntally, wc may 
take a watery oolution of the oommon phosphuto of 
soda, and dimolro uric acid in it, but only to such an 
vxteot as to cusum tho Buid n.-nuiiuing olkiilinb; a 
diminution of this reaction by thu subsoqueiit addition 
of a weak acid, will caose tho precipitutiou of uralL- of 
soda ; but If the fiuid is rendered acid, crystaltisatioa 
of free uric add will ensuo. 

By the adoption of these ^iews we are eiifiblcd to 
explain why difTcifDccs exist in the olasses of exciting 
caofiOB ; for wo have found that same of them are of 
the Sttmo nature as thoae whidi predispose to gout, 
but that otlierv, however long their action is OOH' 
tanui'ii, aro jKiwcrlces as predispusing agents. We 
Duw m-o tlict reason of these diStTcnccs ; thoeo agen- 
oieA which, when iu active operutiuu, load to a imptdly 
augRK'tited formation of uric acid and the produotioii 
of a fit, must ncoe^arily, if in slowin* action, prodis- 
po!i(> to the affection ; when-us ngcnciiw which simply 
diminish tlie alkalinity of the serum, and render tho 





AUTHOR'S V1KW8. 



m 



I 
I 




I 



urate less noluble, cniiuot of tlicmsolvee in any vny 
pruduGo the difvnne ; tbi» cold, v/Wwh so ofteo excites 
n lit of gout, nerpr induces n gout)' habit. 

"SVo have lastly to discuss the leiil/t proposition, 
niuncly, tliut in no other disease but true gout is there 
a dcpDsitioii of orsto of Boda in the inflamed tissues. 
lu at leust a duzcD cases of patients who had xulTcn-d 
fiuni gcuuinu rheumatic fever, I have examined soino 
of tlio juinbi known positively to have been affcctod. 
Soaiu of the joiubi, roccutly inflamed, liaro exhibited 
inercMcd viisculurity, turbidity of the sj-novial fluid, 
opacity of the curtilu^e, and otlier martu of infionuna* 
toy action ; but in no one case baTo I 8een the 
Bli{^it«8t dq>oi>it of urate of «oda. Again, in nnnuv 
nms casL's of rheumatoid, or ctiromo rliroimatic arthritis, 
observed both by myself and others, although tho 
itlugcfl have always shown agae of inueh injury', 
inm the cfibota of ulceration, yet no urate do|xwit has 
been found. I may hca- state that it has been 
USNted tliut urate of soda is somclimex prc^iit in 
jwiitK which liud not been afrect«d with gout during 
life, unil one sueli case is related by Ur. Barwi-11, who 
exhibited vi-ry n-cctotly a diseased knoc-joint, mp- 
posed to be in this condition, bcJbn> tlio Pathological 
Society ; but ou can>ful cxaminntiou I found tliat the 
deposited matters, which had rt^Iaeed to some extent 
the ubfiorbcd cartilage, oon«i*ted of phosphate and 
carbonate of lime, without a traoo of uric acid. Id 
an examination of the great toe joints, in at Inut forty 
oases, 1 hare known only two instances in which oris 



330 



NATtntE OF OOUT. 




«cid has boon dlsoovcred, and io botb these it occurred 
in one foot only, itnd wti^ Uniitcd to a single spot io 
the cup of the first phulanx. Ono of those individuals 
bad boon a cabnuin, aged fort>'-eight ; bad granular 
kidn«y6, and had died from an injury ; the other was 
u miiD ngLMl forty-thrcp, who died from delirium 
tremiiis ; in both easws the spot was niuilarly situated, 
as rpprosentud in the annexod wocidcut. I have no 
doubt that many persons 
experience extremely slight 
attacks of gout before the 
development of the affeo* 
tion iu an aoute form, and 
^ **•■' Bovcral patient* h«vi> as^un.'d 

mi> tliat for years before tht-ir first severe nttnck in the 
gi'eat toe, they have experienced flight twinges, whi«h 
have occurriHl periodically. I am quitfl of opinion 
that when suoh twinges occur, depoeition has already 
taken placf . 

Having enumerated and conHidered these propo- 
fitioii^ we will iiftst f-ndeavour, by their aid, to 
vx|>liiin cert^iin poculiarities which are met with in 
the proi,Tess of gout, many of which have proved 
of great difficulty to patliologists ; and first, with 
regard ia the phenomena of the tit. It is essential 
for it« production that tliere should be an impure 
condition of Uie blood Irom the presence of urate 



• Pig. 30 ttpT»ent« the eiip iif tlio firat rh&lanx of t|i« gro»l |ne 
coninlniuj ± ipcclc of untc of wJb ; frum n mu vho dicJ gf ilclliiam 

tniBtti*. 



Aimiomi VIKW8. 



au 



of «ocIu, nn<I guch imptirity may be induced by Um 
ctioD of liny of Uio prcdispoidiii; causes of tlio dt>- 
iind is i>r»bitl;ly uf itself suiGcddnt to gire rise io 
tliL< proBKinitury symptoms wbtdi ore cbiofly niuu> 
fo»to<l in Uio fuootioiuit dcrftngemcnt of tbe digestii'e 
und i-ircitlnting organs. To oxcit« a gouty paroxysni, 
litiwfvor, rccjiiires the additionii] operatioa of other 
ii|^'nl», DBnioIy, of those by wfaicb tlie urate of auda 
is oitlior (iudd>.iily niigmcnted or n-ndercd loss soluLte, 
uid its cT^atallisatiou ooosG^oeDtly promoted in the 
Ugniiientoua and cartilaginouB stmcturce af the joints. 
The intensity of the pain vhiob usually accompanies 
ft gouty fit depends upon the H^ditj' of the puts, or 
the state of tension within the joint, for it is oiily 
whoa tJi« iutlammation is inter-nrtictdar, tlint it is so 
peculiarly intonso ; when coutinml to the niore rapcr- 
tivinl struoturea around the joiutA, tlie i>aiii in gout 
has uot appeared to m« to bo mora severe than that 
which occurs in many oUicr iuBammatiiry diswsos. 

A peooliarity of gouty iufliLuiointioo, duecnbed io 
our second chapter, is tlic i>ct;unvncc of a>demn. and 
tlie subsequent dc^uiuiiation of the cuticle ; them 
eymiitoms are of w>mo importance, os they are sa 
ftoi|uent in gouty, so rort in rheumatic inflammation. 
An explanation has been bervri- hinted at, namely 
that the (edema depends on the prewnoe of urea in 
the blood, and w« have seen that this i-i fn«)ueutly 
the eoao, and likcwiso know that in albuminuria, 
where the elimiuation of urea is greatly impeded, 
odemft becomes a prominent sj-mptom ; and in scorta- 



333 



NATURE OF GOUT. 



tina, whore the kidneys nre so liable to be affected by 
the pciifluii, dc^q nam n lion of the skin is n oharactcristio 
attendant. I cannot htilp tliiukiug that the abovo 
may he the truo explnuation ; hut iu order to prove 
it beyond doubt, eertoiii clinical und chemical obsorra- 
tions arc required which have not yet been satisfac- 
torily made. The occurrence of chalk-stones, or gouty 
tophi, which has eo long been n stumbling-block to 
tlioRe who deiiioil the existence of iin iiltcred blond, is 
now easily esplained; eetrif ptiroj-ysm 0/ gout it 
atlet'ded tcith it dfposH. 

Sir Henry Holland romaikft that a difficulty in the 
history of gout, aud tme not cosily rcconciliiblc with 
the view of the disease b<^-ing dopendont »n a mnU'-iea 
morhi, is the fact of the frequent attack of Kome jinnt 
with gouty pain and swelling, iA-ithout any well marked 
symptoms to give warning of itit approach ; for it ia 
necessary to explain bow tlto matter, capable by 
accumulation of producing an attack, should have 
been doiraant up to tlie time of tlie seijiure, and why, 
latent thus long, it should suddenly show itsc^lf ia 
the production of acuto disease. These questions ho 
confesses could not be answered at the time he wrote. 

According to our view their solution is a very easy 
task, for we have shown that the mere accumulation 
of the urate is quite unequal to tlio production tS 
inflammation, and that Its actual deposition in tissue 
is essential, an occurrence which usually requires a 
peculiar exciting cause ; and hence in many ca-scs there 
may be no well marked oymptoms to giro wanting of 



ArnioE"s TiEwa 



m 



the approach of a fit, nod hcnco nlso Uic poison may 
lie dormant for a cousidcniblo timo, but wbca ciyttol- 
lisatioD of the »ilt tukes place in any iis^ac. iiiflommn- 
tiuu is suddenly lit Up by it« prCMDOO, and a paroxysm 
of gout ensues. 

QuOitions in the history of gout of much greater 
difficulty t« solve, an: tho fallowing: — 

AVhy docj gouty infliimmation in ita earlier attacks 
peculiarly select the bat) of the great too ? and why, in 
the snWqueat progress of the muludy, iire the affected 
joints more numerous P 

To answer the first of these qucstiunii has been the 
attempt of many physicians; Sydenham says "the 
foot aro the gonuiiio 8CHt of tlie {leivant matter, whidi 
may without doubt fix itself on other parts; bat in 
that cose it is plain that cither the progross of tho 
distempiT is inverted, ur the patient's strength, from 
repeati-d attacks, is gradually iinp-iired." 

Bovrhuarc hiis an aphorism to tlii^ cSvct, that tlto 
part which gout first and regularly atttwks is always 
th« foot, and chiefly thow tissues which tho fliuds 
have most difficulty in passing through, as the peri- 
osteum, tendons, nerves, membranes, and ligaments, 
and such as ore most remote from tho heart, and most 
pressed upon and injured. His commentator, Van 
Swielen, ttild», tluit oon^idcring tho difficulty with 
whicli the liquids pom through these parts, no impro- 
bable notiuD may bo formed why gout is gooorally 
obaerrcd to oominonce in them, u they aoffer great 
pKMuro from having to BOKtain the weight of tbo 



SSI 



NATURE OF OOUT. 




whole body, and bcin^ fitr remoTod irom ttio heart 
aru Eubjoctcd to the iiclioti of cold aod moisture, sod 
thu bloixl brought to them by the arttirios, whoi 
rctuniiiij,- tluviu>;h tlic voitis, has the force of grarita* 
tion to overeoinc. Tin- fvit lire also peculiarly liiiblc to 
bo hurt in walkiiig, lenping, Huddcn fidk, and acddenta. 

I boliere there is tnudi tnith in these remitrks of 
Doorlioave and Van Swiftnn, although the stato of 
pntliolog)' nt that period did not idlow them to advance 
further in explanation of tho 8ubject. 

There ore many oircumMancen which cauftc tho 
groat toe to bo selcctod for the firat deposition of gouty 
mattvr; it coutniuK, fur excunplc, in iibuudaiioc, tho 
tissues porticuturly prono to bo affocttt], niuncly, thoM 
either of little vascularity, or nourislied ottogi/tJicr 
indupondeiit of bloml- vessels ; it w likewise very 
rcmuto from the heart, where tho forcn of tho ciruuln- 
tion is at its mioiinum; in addition to this, the 
motutorso-phalangeal joint is one which is subject to 
prossurc and injury from hanug to support the weight 
of the body. 

In connection with this point I may mention that 
in the examiimtiou of this joint in many individuals 
who liavc never expeiicnccd syiiiptoms of gout, I have 
commonly found distinot evidence of iujury on the 
surface of the cartilage, loth of the heud of tlie mota* 
tarsal bono and of tlie cttp-Iikc ciivity of the phalanx, 
when these iippoaranccs were not present either iu the 
corrosponding ynnin of the other toes, or in any of the 
phalangeal articulations. 



AnriKIR'S TtEWS. 



MS 



Very Noently with the aid of Mr. "Wilmot Power 
of tTuiverdty CoUego noapital, I have been ouaMed 
to obtain soiiio dcfuiito iiumuricul Ti«tiIU on this sub- 
ject. Itwides the 81'vi'ra] ciuww just ni(nitioned, of 
vbiob the gmGral impix«sion ouly is recorded, tlio 
CMidition of tlic great toe joiiiU vas onrefull)* notod 
in twenty cases io which no gout had pxidt«d ; in six 
only were botJi jointa found absolutely heidtJiy ; oiio 
toe was healthy in three casca ; but in the remiuniug 
olorcn cases, botli tooa were affcfctcd with ulcvration 
of tho eurtilago to a grcati-r or It-ss extent. Tho 
foUowiDg tabular arrangement shows the prinGipal 
points of interest : — 



Cnh. 


Bex. 


Aft. 


otgn^ Mft 


1. 


7nn»l«, . 


•7 


Bifbl, hnttbr- 

LtR. lUgbt nlcenltan In caitll^l 














of ODp vitli * •null }«Uav ^M 
Bight, (klot olcvMion ia outitac* 


9. 


Fnuh . . 


n 








ofmp. 








Lttt, bioUt. 


S. 


P«D>ll. . 


as 


Ulgbt, tnc* of almBtion in oulihca 

of mp. 
Ltrfl, iciifirljr ■ (no*. 


4. 


Um»lt . . 


61 


Riiihi. Itint nlmnriinn. 
Le\ hint nlniMtMi. 


S. 


F«m>]«. . 


3t 


KUhl, btdllir. 
LtA, boUUir. 


a. 


Pciulc . . 


<1 


Algbt, leiT «U(lit slMniiiin of cm- 














Lift, on* qurlcr of articoLu imr- 








Uem, dwnM oampUMlr at t»t- 
Bl«bl, hmUhj. 


1. 


iMlt. . 


«i 
















artil*■■otM^ 





F 


>■ 


1 


^^^^1 


■ 




^^ 




^M 33a NATmiE OF GOUT. 


1 


^H / 


Cw, 


Six. 


*K*. 


CosdiUoD o( KaUurB-iitMluigMl Jelnt 
oT lb* gnu m. 




8. 


lUl* . . . 


3S 


lUilht, hint nloentiDa of carlils^ 


^^K' 








of cap. 












Ltfl, healthj. 






S. 


Mala . . 


40 


]tl)l!i[, iDino alcontion of (artllaga 

of cup, 
Ijoft, ulaiitiit'en noil* markod. 






10. 


KtXo . . . 


4S 


Hi Kb I, bmttbj. 
Uft, heallliy. 






11. 


Mole . . 


29 








la. 


Mala . . . 


B^ 


Iliicht, flup nod hoaJ nlcentfid 

to the HLTUD nxtook 
Laft. tlic nmo. 






13. 


M»lc . . 


z» 


night. Iiciittl>]r. 
Lnrt, btklthy. 






U. 


Male . . . 


a 


Ujj[l]t, mnall upol nf nlwntion at 

nuWr mliw of «iip. 
LflfY. wmmtncln^ ulocmtitm^ 






IG. 


Mala . . 


£2 


Rlgbl, ciral ulceration lu oinllaga 
efcup.aiicliiiiiall ulociutioD a( btail 
of \naa upiHuiUi tint !ii cuji. 

Lrlt, slight ulconlino in top. 






10, 


MulD . . . 


34 


Riiihl, vpryfaliit uWntioti of cartE- 

Idgp nf I'll p. 

Left, iligbl oloDration of oarUlagt 
of cup, 






IT. 


Hilt . . 


47 


Right, Ditcurire and 'roll narked 

ulMration of aap. 
Loft, iligUt ulctratioa of cartlUgo ef 






IS. 


M»U . 


31 


Bij{tit, irrj faint nWration of oM- 

Um nf oiip 
Iirft, iliglit ulMratioo in eartil*^ 






IB. 


Male . . . 


Sfl 


lUsfat, baallhj. 
led, buUthy. 






SO. 


Mala . . 


34 


Right. Iioaltbr. 
Left, bialthji. 






Lastly, vre know that certain poisons are, as i 


J 


^^^^ were, attracted to particular parts, and the estcmat 


^^^^ phenomena displayed by their action are luually sj-m- 


^^^H metrical. This is exemplified in many cutaneous 

Cv 1 



ADTHOBTS VIEWS. 



air 



Tho same power of selection is shown in 
tt^ienon of many drugs; tlius digitalis acts on the 
heart, opium oa the cerebrum, and stryolmia on the 
fpmaloord. 

In answer to tlie oecond quMtion, why nomorOBS 
joints are implicated in advanced gnut ; tlio fbllowingr 
oppors to be the probablo c-xjilunation. When tho 
discMO beoomca engrafted into the syst«m, tho unonnt 
of urate of «oda in the Wood i« atigmtMitcd, and re- 
quires more suificea upon which to deport itself, and 
henoo other joints in addition to tho great toe «o 

F'toloetod ; moreover, the cartilages and ligaments of 
joints lirst attacked, after a time become ootD* 
Jy incrustcd, m much so indeed that the boll of 
the grottt toe ia in many cases ancbylosed, and con* 
Tortcd totn n solid ease of urate of soda, so that no 
further deposit can t»ke place in it. 

It ii) interosting to observe tho regularity with which, 
under ordinary oircum^tances, tho joints are impU- 
oatod. First tho grmt Ux*. then the hecU, and ankles, 
•ftonrards tho knees, tho smaUer articulattoiiB of the 
faaods, tho olbowf, and lastly (ho shoulders and hipsL 
Tbarc are it is true many exceptions to such asequcnoe, 
bat these can usually bo accounted for by the 
oocoircnoo of blows, sprains, or other injuries. It wilt 

'ht obsorvod that this order has a close relation to tho 
oonditions which favwir tho deposition of the urate of 

.Boda ; for examine, the heels and aiikloH are much ex- 

I posed to preesuro, and are also remote from the heart ; 
the IcDeea are likewise under wmewhat amilar dream- 



S38 



MATtTRE OF GODT. 



stances ; the hips and shoulders, the least frequently 
Affected, are the joints in which the circulation is most 
ootire, as thoy are near the large arterial trunkB, and 
Uie obstacles to the return of venous blood from 
them are slight ; they aro also protected by thick 
covcringa of muscular tissue, 

When deposits are formed in the more oxtemul 
parto of the body, those are commonly siclcctcd in 
which tho circulation i« slugt^ish ; thus we have found 
tlio helix of the ear to bo a fevourite point, and pro- 
bably this organ is colder than any other portion of 
the frame. I have before mentioned that in my es- 
pcrienoe, vhen patients have had chalk^gtones about 
tJio joints and not in the cars, these latter wore warmer 
Ulan luual: I do not remember ever having seen them 
in the ears of women. May not this arise from llicir 
being generally kept warm by some covering? 

Tho next question which naturally arises in the 
course of our inquiry is, Why do depodts of 
urate of soda constantly take place in ligaments 
and cartilages, or closely allied tiiiaucs P One reason 
may be that these structures possess but little vascu- 
larity, and the deposit is at once placed beyond tho 
further influence of the blood-vosseLs, but, in addition 
to tliis, it is probable that the fluids of these tissues 
are less alkaline than those of many others, and oer- 
tsinly less alkaline than the blood itself. Sometimes, 
in old gouty cases, only a few hours after death, tho 
reaction of tho synovial fluid in the joints becomes 
distinctly acid, but that this is not constant, will be 



AornoR's VIEWS. 



m 



KCQ in the Cbcoomits o( several of the diueotiaDS in 

rObapterVI. These two circumatanccs, the sligbtviuicii* 

']nrity of the tii^uos and the diiuiuii^ed gdkuliiiity of 

tlio fitiidii, probably oxplniu why Huch ports am mora 

frequently atUcked than others, 

"Why are females comparatively exempt from gout, 
at loast in its more regular ma&ifeGtationB, and why 
does tho disuusu tu gildom ultuck young people? 
Those queetiouK ciui bo readily aoewcrcd. "Women, 
althougli liable to the influcncu of hereditary predis- 
position, are to a great ext^ot Iroe from tho action of 
many of those extraneous causea which boUi induoo 
and excite gout, more especially excesses in wine and 
. matt liquors ; in addition to irhich they partly owe 
their immunity to tho occurrence of the catamcnial 
diHchnrgc during many yeat^ of adult life, which con* 
stantly tends to rid the system of suiierlluoua hlood 
without engendering debility. It is aAer tho ocesatioa 
of this function, or whou it has become urosted by 
ooddoatal causes, that gout is most apt to dcvcl<^ 
itself) and tlio iiphorism of Hippocrates already ro- 
forrfid to is pntcticatly correct. During youth, when 
tlie growth of tho b<idy is rapidly adraocing, and 
excess of nourishment is required to build up the frame, 
[ and wliile the socn-ling functions ate in [ah actiTity, 
[llioro is little teudency to engender suoh a state of 
' Uood u would load to tho dew lopmont of gout, and 
youth moreoTcr is seldom Bubjeci to many of the 
prcdixpoatDg caosca of gout. 
It would thos appear that hereditary predisposition 

■ 3 



SIO 



»ATfRE OF OOUT. 



nlonc is tuioqual to oauso the development of gout, fttid 
ttiOTO urc many ftxamples on record of men stiiingly 
iuhoriting the afFection, pacing through life without 
an attaclc of tlic diitordcr; hut in them, as well as ia 
women, it L^ common to fiud strong evidence of their 
«onstitiitionul tendency lu the maniicst«tion of many 
symptoms of the mattkcd forms of the disoon ; the 
same is occasionally witnessed in young people. 

Lastly, it may be a&ked, Wliy does gout almost inva- 
riahly rocur, and why does it at first exhibit signs of 
periodicity in its returns ? 

^csc phenomena are explained by the fact, tlmt in 
gouty siibjccfs an impure state of the blood is g«ae- 
rdly present, arising citlier from an increased forma- 
tion of uric acid in the system, or from its dwffCtivo 
elimination ; when, therefore, ^ay exciting cause is 
more than usually active, a 6t b at once induced ; in 
the early stages this usually happens in spting or ill 
•utumn. whou the circulating and secreting organs 
arv peculiarly prone to duddcn ilcrangcincntji, but after 
It time the seizuiea lieconie more frequent, and urc 
brought oil by the opeiatiuH uf tlie alightcst irregu- 
larities. Now and then only a single fit occurs 
during life, hut such cases are quite exceptional. lu 
individuals not hereditarily predLspitsed to gout, great 
care in diet and regimen, and a completely altered 
course of life will somotinies prevent a fiirther recur- 
rence, even after several attacks have been expe- 
rienced. 



TBUTUfiHT OP CODT. 



Ml 



CHAPTER X. 



TRUTaiiT or OovT i— tnon utu« or thi tkutmikt Uiorttu 
m mt AHOtDcti— li «oir* a cnuiu pmuta t— csllbx'* 
ornrioi — icTni>i'i Tiim Mr rat ritva or Ruura » tm 

DttflMIt ninU vr OOOT — IKUTIHKt OF XRTS OOVT — MM 

jm iMtm— Till v*ii;i or roso^nm— aiaovuiij — ibmb 
■a/numra irracn m aur »■■•— bidutim ia» PurnouiKS 

— ■UWD-LRttm— Oi'LCUICCM — bOCll. TIUTaiST— !■■«■■»— 
MVma — WAIUi *»FLlClTIO»— CriroUTHil tATlOW— 1»0> 

BTMo— (UMXiM «r Tni TKaATUKVT or tax ooctt rxaaxnot 

^B general plan of treating gont adopted by the 
ftncirnt* him been already sufficiently indicated in onr 
introductory clinittvr, fmia whicli it may be gathered 
that phyncians of ol<U-n tiino" liad recoimo to fre« 
ilop toti on by the U90 of btc«ding, purgntiTes, and 
emetica. and often coinbiued n-ith tlww, thp nnplojr- 
ment of the hcrniodiMtylnfi ; at tlie Mun« time ifacy 
enforced abetinonoo in diet, especially at the oonunooeo- 
maot of the poroxj'HD. They also had tvcoonH to local 
eppUoneca, as aoariftcationc, fimkontalioaa, and emollient 
oiutmenta. During rocorery a mora genaons diet 
aitd itomachioa vera ulluwiil, aiiU fnctiuu of the 
■fiected jointa Aroqoently enjoined. 

^KM romedial methods were doobUeas fouwlcd on 
their ideas of the nature nf the disease and the best 
meiuui uf getting rid of the oSondiag nuith:r fruut tlio 



BM TKEATMfUfT OF GOUT. 

systom, but the licroic pluns tidoptotl, howevor nvmlable 
st that time, ^i'»u1d ci'rtniiily ill-$ui( the gouty of Uie 
present generation, for whom wo must now endeavour 
to point out the moans most likoly to conduce to the 
nlloviation and cure of their sufferings. 

I.* it piiwiblo to euro gout? n* an inquiry not un- 
froquontly mndc, and Uie conclusion generally arrived 
at is by no meJins satififactory either to patient or 
{Aysicinn. An opinion hna long prevailed, not only 
■mong the ptiMici but likcnHso in the profession, that 
gout is nitiigi'thcr an incurable malady ; that gout 
oleiio is the cure of gout, or in other words, that a fit 
of the disorder 13 essential to rid the system of the 
impurities which have hd to its jiroduotion. Such an 
idea probably arose from the remarks contained in the 
writings of some of the ablest physicians upon tluH 
subject ; in the works of Sydonliam, wo find the fol- 
lon-ing piLsnage ; " In gout, it seems os if it were the 
prerogative of Nature to exterminate the peccant 
matter after her own fashion, to dejiosit it in the joints, 
and afterward'; to void it by insensible perspiration ; " 
and Cullcn, looking upun gout as a disorder of the 
whole habit, and often depending on original confor- 
matnon, considers it probable that it could nut be cured 
by medicines, the effects of which are always transi- 
tory, and BoldoTn extend to the production of any 
material change in the economy. Cullen also oon- 
Eiders that it would perhaps havo been fortunate for 
gouty puisona bad this opinion been implicitly received 
by them, as it would have prevented thoir becoming 




OKTEBAL CONSIDERATIONS, 3rt 

M often the dupea of quacks, who cither tTifled with 
iDcrt modicincB or raslily employed those of a perni- 
cioua tendency. 

Although individuals, originally posscseed of strong 
constitutions, now and then experience periodic attacks 
of gout, somctimefl for more than half a centuiy, 
irithout appearing to bo materially injured by their 
cocorrance, yet suoh cases fonn the exception to the 
general rule, which is for the tliscaso to bcicomo more 
chronic in its nature, for depositions of urate of soda to 
increase both in and around the juiiib<, producing tiiS- 
DOfis and deformity, and for the eliniinnting power of 
the kidnej's to become gradually low effieicnt. It is 
true that a patient often feels much relieved after a 
severe 6t of gout, for the nyiitem by this means hai 
rid itself in a great measoro of impurities which were 
previously cuusing many distressing symptoms; a bot 
wbioh gave riso to the opinion of Sydonhun, tlmt 
tho more nolent the inftummation the shorter the 
paroxymn, and the longer tho interval between it nnd 
the next. 

Dut wo have already eeon that gouty attacks, 
although tltey may be in a certain degree regarded as 
curatiTO, ore also destructive, nnd tlmt a deposition of 
the morbid principle invariably occurs in the infiamed 
joint, henoefortli to act in »ome <U'gToe as forei^ 
matter, and not nntrequently to lead to ulterior mis- 
chief. Tlda view i^ the pathology of gout being 
ostablished, it is only reasonable that our endearoura 
dbould bo directed to prevent lliu formntton, and aid 



gu TBEATSI£HX OF GOUT. 

Hod expnisioii, of the impuritios bj' other ohaonelA than 
&e flliicolAr surfiices, and not to encourage the fit, OS 
has been sometimes advised. 

My own opinion as to the value of tretttment in 
gout, derived from an extcneivo experience, is — 

Mrst. In the acute form, gout is as controllable 
and as much under the influence of remedies as any 
other inflammatory affectioo. At the same time I 
n'ish to lay great stress upim the nature of the treats 
mcnt, fccliiij; fully conviuood tlmt, not only the 
dnratioD of the piiroxysm, but Ukcm'iso tlie injury 
inflicted upon the joints, depctids upon its judicious 
administration. 

Secondly. Tlie more chrouic forms of gout, which 
are mot with in every degree of severity, are likowiso 
under the control of the physician, if not for their 
rndical cure (and this eon Kcarcoly be looked for when 
crippling of the joints and extensive <Iepo»its have 
already occurred), yet for so much relief as will enable 
the patient to enjoy life, and prevmt tho further 
increase of mischief, which is so prone to ensue, if Uio 
disorder be allowed (o run its own course, and more 
cspociiiUy if recklessly tampered with. 

Thirdlij. As gout t$ u disease which is not only 
apt to return with increased severity, but to acquire a 
firmer hold on the constitution at lach visitation, it is 
a matter of seriouM moment to consider whctlier it 
may not be prudent in tho intorvoLs of the attacks, 
not only to regulate th« diet and r(^:imoa of tho suf- 
ferer, but even occasionally to have reoourEo to some 



GE^'ERAI, CONSlDEIUTlOXa 



Stf 



means, scarcely to bo <!allc(l mcdioinAl, hj which Uio 
blood may be kept free from Uicuto impurities, which 
by Uitfir occumiUHtiou lead to tho produdioD of the 
puroxyGm. 

Tho trcatmont of gout founded on Cullon'sapborisDi 
of trusting to patience and flannol is to be highly 
doprccated. It may indeed bo nrf[ucd, that it is tho 
natural treatment and that Nature is a sure ^de, but 
it must be romejnborod that man living in a cirilised 
state is not in a normal condition or in all probability 
be would never hare acquired the discnso, and that 
whi^n suffering From a di^urdcr ito aofiuircd, ho must 
be content to have rccourso to artificial rcmediec If 
ho could entirdy lay aside his usual habits, and follow 
in all rc!!i)ccts the dictates of nature, there would 
probably be little need to eeek relief from mediobe. 

I shall endeavour to point out the means beet 
raited for the majority of patients in the different 
etngtxt of gout ; but all who have had expcricnoo in 
■elinical medicine mii*t be fully aware, that each indi- 
riduid case not only exhibits its own pocolioritice and 
becomes a wpnrato i^tudy, but likon-ise demands, in 
certain rospocts, a special treatment The neglect of 
this oonndoration, which is apt to lead to a routino 
practice ckMcly bordering on empiricism, has tbiown 
no little obloquy on tho science of medicine 



Trmtmntt 0/ Acutt Oeut. — VThca ailled to a patient 
ftoffering from au early aitd acute fit of goot, we should 
follow the TtdoB which apply to the troatmeot of ord>> 



3ia 



TKEATMENT OP GOUT. 



nary Jnflarnraation of equal intenfflty, slvays bearing 
in mind that >t'o aro dealing with a disease originating 
in a peculiar condition of the system, wliich ii oapablo 
of considerably modifying the various f^-mptoms that 
may present themselves. Esoept under peculiar cir- 
«auistances, a strict antj]ihl<)gi8tia diet .ihould be 
enforced, but as tlie appetite is sometimes keen, this 
cannot on all occosionx be easily necomplished. Ex- 
perience convinces mp that in many instance^ a fit of 
gout is prolonged to an unnecessary degree from suffi- 
cient regard not being paid to this point, and many 
patients have informed mo that, whereas under a 
regimen in which animal food was allowed, they were 
accustomed to Buffer many weeks from each paroxj-sm ; 
luider a proi)erly restricted diet their attacks hare 
passed off in an equal number of days. The error of 
alliiwing nniintil food in »uob cases has arisen not only 
fram n wish to gratify the patient's appetite, but from 
a very prevalent idea, that it is of importance in gout 
to guard agniust the occurrence of debility, and that a 
nutritiona diet is ueccssaiy to secure this end. On 
consideration, however, it must be evident that the 
lowering of the sj^stem induced by the long continuance 
of inflammatory disonse far exceeds any trivial debilit)* 
whidi can possibly be caused by tho necessarj- absti- 
nence ; moreover, in most patients tliu-s circumstanced, 
altliough appetite he present, the digestive powers are 
weakened, and animal fr>od taken at such times aid.'i 
greatly in augmenting the impurity of the blood, »nd 
consequently increasing the gouty condition of the 



■ 




D!ET AND ItEOIHES. 



«1T 



habit ; in additian to which, such ft diH luis a tcadcncy 
to keep op a fobrilo statfi of Ui« sj-stem. 

The rules of diet in ctiaott of acute sthenic gout mnj 
be thui shortly (iiiinmcd up. The patient should be 
confined to a diet eon-sisting nf little more tbaa 
diluents and farinaceous food, until the diseaiio has 
shown a decided inclination to abate, indicated by 
diminished tension of the skin, mitigation of tlio pain, 
and the ready production of pitting. Such n diet 
would include bread, arrowroot, sago, tapioca, and tho 
like, with milk, tliin gruel, barley, or toast and water, 
and weak tea. Tho drinking freely of diluents i« of 
f adrantage, as it keeps up the netion of the skin and 
kidneys, but stioiulating nr nicobniic beverages should 
bo fitrictly forbidden, or the fit may be greatly pro- 
longed ; as an instance I may mention that a lady 
once informed me tliat she hud sufiorcd from aa 
attack of gout for the space of six months and the 
only cause to which such a lengthened doration could 
be attributed was the circumstance of her hating 
token two or three glasses of port wine CTcry day, to 
combat a feeling of great prastrntion. 

Now and then, it it* tnie, cticumstanoos arise whidt 
render it ndvisablo to relax somewhat, but I am oon- 
Tinood that in acute gout their occurrence is rare, 
and wo should not too readily be led to d«>iato from 
the prescrilied plan fnnn tho mere sensations of the 
patient, but be guided by the state of the pulse and 
other objcctivo rntlier than subjrctive sj-mptoms. 
"When the febrile disturbance has obatcd and the 





TRE-kTSrE^fT OK GOUT. 

local alToctioQ ha^ become distinctly relicred, a return 
to a more nutritious diet may be allowed, taking eare 
that nothing likely to ciius^ indigestion he given; 
beef-tea at firtit, and then white fi^b, oftcnrords fowl 
or tender meat, but this latter in moderation, for wo 
must remember that everytliing beyond what is abso- 
lutely required for the nouriabment of the body only 
ieeds the disease. ISven at this stage it is usually 
imprudent to havo recourse to alcoholic stimulants, 
but if really necessary to promote digestion, a rery 
small quantity of biimdy may be given, freely dilutt-d 
either with plain or nCratod water ; hoUands or 
whiskey, if piofcn-ed, may bo eubstitutod for brandy. 
If wine bo taken, a little sound sherry is most suit- 
able, but we must remember that wines of all kinds 
possess a much greater power both of inducing and 
exciting gout than distilled i^iiits. Mult liquors 
should be altogether probibited, as especially prone to 
oause a recurrence of the parosj^m. 

When febrile disturbance is present to any extent 
^ in acute gout, the patient should keep his bed at least 

^B for a day or so, as too early exposure and exertion 

^H sometimes cause the inSammatioa to leave the joints 

^H and implicate more important organs and instances 

^B of this kind in which the brain bos thus become 

^H affected, and deliritun produced, are not uncommon. 

^^ On the other hand, too much warmth and inactivity 

I is dceidinily injurious, inducing debility, anJ prevent- 

I ing tho due action »f the various orgaus of the body. 

I In former times niuny advocates were found for 



GEyKRAL CONSIDEBATIOSS, 



in 



attempting to drive oS the paroxysm of gout by 
extreme exertion ; this may perliups be sometimtj* 
successful when u mere thivatening existis l>ut not 
vbcn mBsmmatioD Euu cfltublisticd itacLf. On tho 
subsidence of the 6t, modcimts wul gmdauUy iocrcucd 
exertion is of much aeniec, and likelv to prevent tho 
injunxl joint from reuioiiiiug Miff and ncak. 

The medicinal treatment of gout may be diridod 
into the general and locaL 

Tho con^titulionul treatment should be directed to 
tho diminution of infliimiuxitir>n and (isbrilo diHturb- 
auce, and the rc^ttonition of tlie blood to a hcaltby 
condition. To oflect the first of tlieso objects tho 
methods empli^yed to aubdue urdiiuiry inihunmatioa 
may bo resorted to, as keeping up the fiocretions from 
the different organs by ptugiitivi'^, ealino diurotios 
and diiiphoretic* ; diminishing tho force and frequency 
of the pulse by viuculor scdutivoiti and aUoriating 
the pain, if ne«csiar>', by tlie uao of anodynes. Tho 
second object l.t b&it attained by giving remedies 
vrhiob have a special inHuaicc upon tho compofittoiD 
of tho droulatiug fluid. 

We vUl DOW endeavour to point out the rolue of 
tho several means which bare been employed in oom- 
bating a tit of ^ut, but it must be rcmeiabercd that 
our remarks on ^mo of tho special remixiics will not 
bu confined to their use in tho acute uttitcks of tho 
disease. 

Purjfaiirei, — Some plij-skaaac h«TO altogether cod* 



i 



3G0 



TB£AT11EXT 07 QOUT. 



dcmnod tho use of purgatives in gout, othora hare 
been load in Uicir pmise. ^Vmong the foraier may be 
mentioned SydcnUam, Mead, and Bocrhaave ; atnung 
the latter, IloSnian, Sutton, and Sir C. Scudnmore. 
Sydenham carried his idea of tho danger of purgatives 
in gout to an extreme, as will be wen in tho following 
pnsiage from his Treatise. "Sure I am that all 
purging, mild or ftluirp, intended to roLiovo the joints, 
is mostly injurious, whetlicr it bo during a fit to 
dimiaUh the pcocant matter, at the vnd of one to dis- 
sipate the remnants of the disease, or during an inter- 
mi&sion to guard ogainat the occum.'nco of one. From 
mj-«!lf and others I have leanit that purges bring on 
what tlicy wi-ru iiu-imt to keep off." Ho then goes 
DQ to explain how purgutires act injuriously under 
theee different circumstauccic, ftud how in his own 
peiwa they had cumpleti-ly failed tu accomplish tlic 
deorod object, und ho u^erto that be has known 
persons porsevcrv in tlus method most rigorously, oud 
yet continue to suffer from gout in its most oggravatod 
forms. Sir C. Scudamore, on the other liand, acting 
upon the indications suggested by bis own \-iow of tho 
naturo of gout, and considering thtit it was closely 
connected with portal congestion, gave purgatiTee Tery 
froL-ly, and more especially thoeo wliich prodacod ■ 
ehulagogue effect. lie commonly employed a com- 
bimilioii of calomel, antimooial powder, and tho cam- 
poimd extract of culocyutli, repeating it each nigbt or 
evcr>' stvond night, according to tliu character of the 
crocuatious and the advantagui whicb appeared to be 




OF PCBGATJVES. 



m 



derived from the tn'atment ; uIoDg with tlicjc he woa 
in tho habit of ordering a draught ooDtoimng sulphnto 
• of magnena, burnt magncsiu, and tho acetic extract of 
colchicum, which hud the oSbct i>f keeping up tha 
BCtion of the bovclg. 

In ^Mxddiig of the value of purgativo mccUdnca 
in tho trcatntcitt of gout, I purposely exdudo the 
pivparations of oolcbicuio, nnt thut oolchieum doM 
not net an n pftwerful cathartic, but because it 
crrtainly dtxa not owe its efficacy to this property, and 
frequently proves of niotrt benefit when its opcrcition 
is nnattcndc-d n-ith increased alvine evacuation. My 
0^71 e-xpLTicnoe has taught me that in tho acute xtages 
of the diifcaso, purgativea poaseas no peculiar power of 
tfissouing the urticulur inflnmination, aud can thercforo 
in no way bo depended upon for effectiog this obji>ct. 
I ant induced to mako thix remark, being awire 
that some prnctitiuncnt look upon the curative action 
of colchicum m duo to its cathartic properties, and 
hare an idea that a like amount of purgation excited 
by other remedies would answer tho same purpose. 
Of the iuoorreotacss of this opinion I am fully oott- 
vinced from repeated clinical observations, and from 
tlie results of trials made to d«tcmune this point, which 
win bo rotated when we ore discussing tho thernpoutio 
powers of coldiicnm. 

Purgatives given in moderation arc undoubtedly of 
value in many cases of acute gout, maro eflpocuUy> 
when accompanied with constipated bowels, reten- 
tion of the bile, and hepatic congestion ; but their 




3« 



TREATMEST OF GOCT. 



offimoy under inicli circunutbuiccx ftimply dopcnda on 
tiwar power of restoring, to a healthy st«tc, functions 
proriously dcrtuigcd, aiid iii>t on tlicir produring any 
apccifio cflbet cither upon the affection of the joints or 
the state of the blood. It is very quo-stionablc if tho 
secretion from tho mucous membrane of the bovcis 
induced by the opcmtiou, cron of hydragogoc ))urga- 
tivcs, contains uric ncid, and certainly not sufficient to 
relieve in any sensible degiro tho o\-crloftded stntt of 
the blood : iu gout we can neither roiisonably hoiw for, 
nor do we find, from the action of hydragopies, tho 
relief which so frcrjuenUy follows their odnuaistrntion 
in cases of albuminuria, or in anasarca dependent on 
cardiac disease. On tho otlier hand, purgtitira; if 
given in doses sufficient to cause much depression are 
decidedly injurious, for nithongh perhaps some tem- 
pofiiry mitigation of Buffering may bo aiTordcd, yet tho 
discufc is rcndcrE>d moreliublo to recuritnd to o^tnimo 
a chronic and asthenic fona. Tho unonnt of cathnr- 
tism must be determined by the pcciiUaritieg of the 
individual cose, for that whidi in one would not ho 
followed by appreciable biconveniencc, in another may 
bo attended with serious prostTution. 

The kind of purgatives most suitable to the treat- 
ment of gouty inflammation, must aL«o depend on 
individual peculiarities; if mere constipation exists 
without sensible derangement of the hepatic function, 
the simple laxatives or milder cathartics may be em- 
ployed, such as munua, magnesia, rhubarb, senna, or 
aloes, or compounds of these, as Gregory's powder, tho 



TALCE OF PURGATIVES. 



«a 



compound rhul)ar1> pill, compound cOooyntfa pill, and 
tho ordiitar)' llnck draught, sufficient only being 
preaorit)cd to insure tbc «Wnco of an undue amount 
of cxoromcDtitinl mnttcr in the alimcntiir)' cnnnl. 
If, however, tbo liver bo in fnult, otlier purgtitirc!> 
may bo advnnta^ody employed, and thtuio should 
be selected which are known to possess an influence 
over the secretion of this organ. Small doses of a 
mercurial preparation, as calomel or blui- pfll, com- 
bined or not with oolocyntb, mny bo giv<>n at night, 
and followed in the morning by the ordinarj- Wacl: 
draught. In some paticutM tbo addition of a little of 
the acetic extract of colcbicum to tlio colocynth pill 
will answer the purpose of the mcrcarial ; in oUien 
tlic combination of the mercurial and oolclticum is 
attended unth beueficiiil results. 

Saline purgutiveH ore fitti^^t for strong and plethoric 
habits, and the eulplmtc of ningnosia, tartrate of 
potosli, and similar saXis, may now and then be 
pvcn witli advantage, combined or not with senna, 
rhubarb, or jalap and some aromatic ; at the same 
time poweifid hj-dragogue action should bo avoided. 



It is acarcoty nw c e wu ry to atludo bi the use of 
Enifiks in the trcatmnit of gout, as they ore only 
called for in exceptional cases. If at the oommcnce- 
mcnt of a fit the stomach be greatly loaded and 
oppROKd, an «DMtio may aflbrd relief, bnt oo inflnenoe 
appears to bo exerted on the progree a of the attack. 
Tho me of those remedies in the treatment of gout 



Kt 



TKEATMEKT OF ACUTE OOtTT. 



iu boon ■ilvx>eatcd by mmo pliysivianB, and Dr. Soiall 
was ftociutumi'cl to \itv them in bia owii onso, omplojr* 
ing tartar omvlio cumkiucd with oinchoiui biuk. 

Mercurial*. — The uso of somv preparation of mor- 
cury as u purgative baa been alrcndy meutioDod as 
occaaionjilly uf advantage in tlio trcatmunt of acute 
gout, but I must hero impross on the reader the great 
unportnuce of caution in its admini»trutiou, and more 
cspoeially to tboM gottty subjects in whom tliere is 
reason to suspect on injured ooitditiou of tbo kidneys. 
In tbcw cases mcrcuriuU, if gi^x-n beyond the amount 
necessary to uet as bopntic altcraots, may be produo- 
ti\-c of most injurious conscqucnci-H, and I havo 
n-itnoMod profuse salirution brought on by the otlmi- 
niHtration of only two grain^t of culomel. Sir C. 
Scodamore, who used mercury rather fixi'ly as an 
alterative, and oonudercd that, if employed with 
judgment and caataoot it was a most valuablo agent, 
ap[)oar(.>d tu bo imprtiied witti tlio fact that when 
given in repeated doses, it was Uiiblu to bo followed by 
serious evil in gouty HubJ(.>ctfl, and in support of this 
opinion relut*.« several illustrative cusos. It can be 
shown tliat mcTcur)' docs not exert any speciiio control 
OTcr gouty inflammation, and hence, cxci.'pt with a 
\'icw to its immediate purgative cfiect, it should not 
bo administered. In advanced forma of gout its U£e 
should be altogether avoided. 

Divi-etict and IHapJiorelies.—Tbe90 remedies are 



i 




VALUE OF AKODVKE?. 



a» 



often of much senico in aouto gout wLcn the urino u 
deSeieot in quantity, and the »kia but and dry. Tho 
action of the kidneys can mually bo promoted by the 
oao of such aalioe remedies oa tlio aoctatc, latrate, 
tattmte, mtTat«, or bioarbonate of potash in small 
doses, or by tlie phosphate of smUa or sulpbalo of 
magnesia given in quantitiefl insufficient to pruduoo a 
potgutivc aetitni. Most of these salts pt)7sc«s the 
pover of altering the condition of Uie bI(M>d by ren- 
dering it more alkaline, and thu^ prove of considcrutdo 
aenioo in Muto gout; on tliis point, however, wo 
shall haro oocaiiion to dwell more fully when upenking 
of tlie treatment of the cIiroDic oflection. When it is 
desirable to induce diaphoresis, the acetate of ammonia 
may be given, taking caro to aid its wtioQ by the free 
luo of diluents. Oocosionally it may be advisabtu to 
pRHOoto tho action of the ^in by the hot air or vapour 
batb, or by the uso of tepid ^wngiog with water or 
TiiMgar and water, hut groat caution must be uted to 
avoid ■ chili to the suriaoc. 



Anodjj/ttet ami Xarcotict, — As an acute gouty fit is 
often Booompanied with intense pain, the queatioD 
of tho propriety of ginng direct utiudj'nes is one of 
somo itnp(»rtunee. That opium ofteu ^)cedily relieree 
tho pain of gout there cannot be a douht, but is its 
aetioD followed by injurious oonsequenocs ^ Cullen 
thus answm tho quoslion: "Opiates give the most 
certain relief from pain, yet when gi%-cn in tho b^in- 
aing of gonty paroxysms, they cause them to return 



A A3 



856 



TREATMENT OF ACUTE COIT. 



with greater violence." Sjdonliam ulso was Averse 
to thfir tuiploymcnt excejit under 8i)Cfial circum- 
stances. My own t'xporicnco lifts led mo to form a 
TCiy similttr opinion, and, unless tlio pain of gout boi 
cxci'^ivc, or thoro be It-ar tliat if not relicTfd the ■ 
pnlienl's ncn'ons system wiU suiVfi', I always feel 
disposed to withhold their administration, and trust to 
other moans, as opiates tend so powerfully to diminish 
the socTotions and to augment congestion of tlie portal 

"When opium is really required, it may be given 
cither in the »olid form or in that of the tincture, or 
of any salt of morphia. It is then desirable to com- 
bine it with a sndorific and purgative, to avoid u 
mudi as possible its baneful influence upon tha I 
secreting organs. The compound powder of ipecacu- 
anha is a useful form. 

With regard to other anodjiies, as henbane, bella- 
donna, and so forth, circumstancca may occasionally 
arise demanding their use, but these depend more 
upon the idiosj-ncrades of the patients than the form 
of tlie disease. Henbane, for example, often pro- 
duces a southing effeot in individuals in whom 
oi>iatcs cause nervous disturbance, and both henbane 
and belladonna possess the advantage of not diminish- 
ing Uio secretions. Aconite has been recommended 
by some, hut its value in gout is hy no meajis 
established. 



Jilood-Letting. — In tlio treatment of on attack rf 



VALUE OF BLOODLETTIKO. 



S97 






acute gout the que.<ttioii of tlic viiluc of blood-letting 
naturally arises, and although its discussion would 
bare hod luoro importance ia former dayo, before tbo 
use of the laDc«?t had fallen so much into disuse, it 
still affords enough interest to allow us to devote % 
few linos to its consideration. 

Sydenham, although he thought bleeding by no 
means a remedy capable uf curing gout, yet undor 
oeiinin limitations sanctioned its cmploj-mcnt, as vill 
bo men, from tho following passage : " Nt'TOrtliolcss, if 
the piiUont bo young, and have drunk hard, blood may 
bo drawn at tho beginning of tho fit. If, bowc\xr, 
it bo continued during tho following fit*, pmt will 
t«ko up ito quarters OTCn iu a young subject, and 
its eropiro will be no government, but a tyruiuiy." 
OuUen also, no advocate for much intcrfcn-uoo in 
gout, thinks some memis may be taken with advan- 
tage to modcmte the inflammation, especially in the 
jfxntng and rigorous, and iu i-arly paroxysms, and 
that bleeding may then bo useful, but he ia per- 
suaded that it cannot bo repeated niUi safety. From 
tho qoalifivd tone in which thd opiniona of thcM 
eminent men were imnounccd, it is evident that 
although thoy occa«ii>uuIly allowed, tbey did not put 
much faith in this romedy, and although tho advan- 
ti^^of general blood-Icltiug were strongly inaicted 
on by Drs. Hamilton, Uu$li, and Huxliam, tho pro- 
^Disioa, at tho prc«c-ut day, seemH lo be tolerably 
tuanimous in ooosidcring blood-Icttbg a tlicmpeutio 
metuts whicli sliould only be resorted to iu cxocpttonal 
cosea. 



I 



3M TItKATMENT OF ACUTE GOUT. 

Dr. Todd considers tLat Llood-lctting, by itwlucing 
asthenia, causes the inflammation to eLifl from placu 
to place, l>ut Br. Oairdnor statctt thot in scrcral casea 
of gout ho has obtained much udvnntflgo from the use 
of small bleedings, as will he seen from the annexed 
qnotation.s: " There arc caaes of plethora ami atonic 
gout which, but for thia remedy, would have baffled 
me, and jet wore speedily and ^-ery thoroughly 
relieved by iti aid ; " and, " It is with me no miCtter 
of doubt, but of absolute certainty, that in tnstaaecs of 
this kind, much suffering may ho saved and no tnjaiy 
done, by the practice I hare recommended ; " but it 
is right to add another quotation in which ho eays, 
" It is necessary I should state that I never mate use 
of this remedy in, and I considor it wholly inappli- 
cable to, cases of gout in an impaired or defective 
constitution, even though there be evidence of pU'thom 
in the ^'stom. I boliovo that some considerable 
energy is necessary to its legitimate use, hut this is 
generally met with in the early stages of gout." 

Bleeding is certainly not curative of gouty inflom- 
mstiou, and, therefore, entinot be looked upon as ft 
remedy hnring any specific power in its treatment 
It can neither remove the impurity of tlie blood, nor 
the deposit wliicli has taVeo place in the infiamed 
structures ; the only advuitogc which can possibly be 
derived fp^m it« use, is the relief of plethora, which 
is mually present in the febrile attack ; hut tliin eaa 
generally be more safely cff«tcd by other ond milder 
means. I have occasionally met with patients with 




LOCAL TREATMENT. 



•M 



acute gout who hare apparently Gxperieneed distinct 
relief from small reneoeotions, bat I have in no 
instance attracted more than fire or six oudcqs of 
blood, frwjuenUy less, and never snfRcicnt to cause 
the «light«(4t pcrmancut debility. From my own 
cicporicnco I am ooiivinood, that whenever blood-let- 
ting has been caniod to an extent to cause subsci^uent 
depression, — and I have seen several cases where it 
has been so employed, — its cfiect has been to render 
tho ftttadts more frequent and prolonged, without any 
advantage in the mitigation of tho paroxysm. 

The following rules as to tho uso of blooding in 
gouty cases may bo safely relied upon :— 

Never bleed with the idea of directly subduing 
goaty inflammation. 

Ifover bleed in advanced gout, or when the consti- 
tatioQ is mnoh weakened. 

If bleeding be roquirod in order to relieve general 
or loool plethora,— and the former, at loait, Rcarcely 
ever ooours in large citic!<,— abfltmot only ao much a<i 
will effect that objoot, remembering that further deple- 
tion tends greatly to aggravate the disease and prolong 
ita doration. 



Loeal Trtafmenf of Acute OaiU. — Shoold we leave 
tho inftamod joints to thcmBelve*, or should wo havo 
rwouno to local treatment f It is of some prnctic*] 
UBportanoo to decide this qncstion c<prToctlyi fur the 
patient, oatumlly anxious for a ^loody relief to his 
suffenng9, is prono to tbtnk that remedies applied 



MO TREATMEST OF ACUTE GOUT. 

iinmetliatoly to Uio paiuful part, are likely to effect 
the desired object; the pliysiciau, on tho otUei' liond, 
may regard coufltitutioiial treatment as most efficacious, 
and look upon local applications as not altogether ua- 
atteuded with dangor. It will, therefore, be desirable 
to pass in renew some of the piincipal local remedies 
■which have been proposed to allo-iate gouty inflam- 
mutiou, and endeavour to nscertiuu their real value 

Leechet. — Our knowledge of tho pathology of com- 
mon inflfummition and of the murkcd benefit derived 
from li3cal depiction, would lead xa to suppose that 
the condition of a joint m acute gout would be imme- 
diately relieved by leeches, and hcuco it is not very 
unusual to find that rvcouTso is hud to them under 
such cii-cumstaiices. Kxp<.'rienco does not sanction 
their employment, as their oppltcution ha^ boon eouc- 
timcs fulUiwod by u tmusfereucc of the iuflammotion 
L-ithor to some other joint, or to on internal organ, 
and sometimes by tho occurrence of a diffuse form of 
inflimimatiou. It has been alao thought by some 
physidaus, that although leeches may occasionally 
give tcmporaiy caw, the recovery is tliereby pro- 
longed, and permnnent weakness of the joint induced. 

If we direct oui- attention beyond the mero appear- 
ance of the joint, and reflect upon the intimate nature 
of gout, and moreover, If wo view tho inflanimatioa 
merely as the local manifestation of a morbid conditian 
of the whole sjntcm, we shall at once find an ex])lana- 
tion of the comparative inefBciency of local depletion. 



J 



VALUE OF BUSTEDS. 



Ml 



My own npiiiiuii of tlic iiiutiltly of local dcplotion in 
acute gout lias bccu so decided, that I have QGVcr 
ordered Iceclics to nii iiiflomod gouty joint, conadering 
that they ore never likely to prove efficacious, uid 
that thoir uae may bo attended with iiijurioua conjc- 
quctiocs ; frota what I havo witnessed of the results 
of their upplioitiou iii casis fur the treatment of 
which I huve 'Ucn r-ubseiiueiitly consulted, I do not 
feel dlqraMtd to oltvT my «ow of their inutility. 



Slittfn. — The use of tho blister as a local rvmcdy 
in gout is by no mean^i of modern introduction ; about 
a oenturj- ago, a woman at ZTors^hom was uocu-stoiacd 
to sell a plaistflr which gained much icpntutiwn, and 
which, after tho purchase of tho eecret, was diMovored 
to consLit simply of the ordinarj' blintcring ociato. In 
1770, Dr. Cartwright tried blisters with complete 
relief to pain ; and Sir B. Shelley ii said to hare osc-d 
them for nearly sixtj- yeare, when suffering from 
attacks of this disorder. Within tlie last few years. 
Dr. Todd advocated the some local treatment of gouty 
inflammatioD. 

From having emjtioycd small blisteni in many cases 
of gout, I have formed tho following concluaons as to 
their ralue, and tlie circumstances under which they 
arc needed. 

Blisters ore unnccessor)- in the early fits of aMhcnie 
gout, whvn the joints arc uot upprcdubly injured by 
prior attacks. 

llioy an oontm-indir«tctl in advanced gout, when 




Stt TRRATMEST OF ACUTE GODT. 

tlio excreting power of the kidneys lias Income im- 
pftirod ; and cspocinUy in case* of extrcitie gouty 
deposits, OS sores may be pivduccd which arc difficult 
to heal. 

Blisters are of most advantiigo in cases of gout of 
an asthenic clmractei', wlion the inflaninuition has a 
tendcnc)' to linger iu tho artioulations and cause 
offiiaou. 

A rational explanation may bo given of the value 
of blisters in chronic and asthenic forms of gouty 
inflammation, as thoy give a tttimultts to the local 
circulntion, and tho morbid action is dircct«'d from the 
tissues within tho joint to the surrounding skin ; 
besides which they eauso ft certain amount of serous 
exudation, rich in matters which give riso to the 
impurity of the blood. 

Tho mam bus now and then been advised in gout, 
and was used by Bir William Temple vritb considor- 
ablo relief. 

Numerous other applications hive at various times 
been suggested by different practitioners, and somo of 
them are deserving of attention. 

The application of tcarmih to tho inflamed joints 
has been commonly advised, and this has been effected 
by enveloping them in new flannel or carded cotton 
surrounded by a light covering of oiled Eilk ; hot 
fomentations and poidtices haro also been employed. 
Some practitioners have objected to the application t£ 
wannth in any form, under the idea of its causing too 
much relaxation and suWqu«at wMkncas, but it is 



I 



LOCAL DEMEDIES. 



tn 



rery qucstionnblc if tho objection to tho uso of corded 
cotton is valid. 

Sir C. 8cudamoro etro&gply adrocatod tho u»o of 
te^nd eraporating lotions to the influmcd joints, and 
advised a mixture of ooo port of rectified spirit and 
two ]urt3 of camphor mixturo. He etatos in his 
works that he hud awd this lotion lukewarm, and 
applied by moati» of Unen ragx, and had found it vor^ 
BQOCOSfiful ; he recommends a tcmperatm« of 75° to 
85" Fahr. The linen compress should consist of six 
or eight folds laid one upon another, and kept con- 
stantly wet ; and in the night, when this precaution 
cannot be alwaj's employed, a layer uf oiled 8ilk 
should be used to prevent tho rapid ornporation and 
drying of tho cloth. Sir C. Scadamorc remarks that 
even the very free use of this lotion has no tendency 
to produce retrocession of the disease. 

Having had but little experience in this method of 
treatment I can offer no opinion as to its efficacy, but 
am inclined to considGr that all applications nro un- 
called-for in the majority of gouty cases. 

Now and then when the piun is vi-iy intonso, reliof 
is gtren by anodynes, and preparations of opium, 
belladonna and aconito havo been used for tho 
purpose. Th':iso of belladonna arc perhaps of most 
sarricc, and an elegant nctliod of applying the drag 
is in tlio furm of a solution of atropiae, mado by di^ 
solving trim two to three gTain.i of tho alkaloid in a 
weak mixture of 8i>irit and mter, and applying it to 
the inflamed juiut by mcoDS of oonproswa of lint, 




IH TEE.VTMENT OF ACUTK COOT. 

or u few folds of linen, preventing evaporation by a 
covering of oiled silk, 

Oucasiunally physicians, from regarding gout as a 
local affection only, liave had rceourso to tho appli- 
cation of cold; and somctijQos patient:!, with an iJcu of 
obtaining rapid relief from their aufferiugs, have im- 
mereod the inflamed limb in cold water, or even applied 
enow directly to the part. 

Such plans of treatment are fraught witii tho 
greatest danger, and cannot possibly be advocated on 
a rational view of tho uaturo of tho diseotic, as they 
aro opt to cause rotroccsaon of tho ortioular iuBom- 
matiou, and tho sudden and 8Cri»u,i alTeetinn of somo 
iQt«nial organ ; at no time do they more than tt-ni> 
porarily assuage the pain, and never exert any la-stinj 
influence over tho severity or duradon of tlie paroxism. 

Tho management required in an ordinary attack of 
acute gout may be thus shortly summed up : 

The diet sliould be very light and chiefly amyla> 
ccoiis, diluents freely used, but no alcoholic (stimulants 
allowed, unksfi in exceptional eases. 

The medicinal treatment should consist in tlie ud- 
miuistratioa of some simple ollcaliuc suliiic, combined 
with a moderate dose of eololiicum. If necessary, 
purgatives may bo given, sch'ct^i'd according to tho 
habit and condition of the patient. lu tho majority 
of ca80«, this vill be found to be all that id ncct-'ssary, 
but in some instances certntii modifications may be 
esseotial ; for uxuniple, if there be plethora, tho qucs- 



LOCAL BEHEDIES. 



8» 



tion of tho abstraction of a few ounces of blood may 
possibly arise : on tho other hand, if tho vital powers 
are at a low ebb, and great Toscular and nervous 
depression exists, it may be desirable to give ammonia 
in addition to other salines ; at the same time the 
colchicum should bo either omitted, or used with tho 
greatest caution. 

The only local application required in the majority 
of cases ia cotton wool, covered lightly with oiled silk, 
but now and then an anodj-ne may be advantageously 
used, and a small blister is occasionally of scr\'iec. 



3II<I 




TREATMENT OF ACOTE GOUT. 




CHAPTER XI. 

TMumBT or ooPT.— coton:oo«— mroiiTjjioK or tub nnuT o» 

in HODB or OPRIUTIOX tSK □ElUICiDtOTTLIIB Ot THK AXCIBR* 

rtosiULT A SFioin or mi^oniicM—oaaiKij. coxrMirtaK or 
ooiouicDM — lis rnTiiDLuateii. iotioh— <u«ativ> xirctm an 
KxrurnAiui bt its puxuaiivi rnorcntt—na iiflcudr or 

THB CIIWUl*rUIO STfTHH — OK TBM nXINK — liR. O&EISTUOb'I 

EiFUUznB^ciBMiiTATium i>r rKortEsafi dniLics — Avruoa'a 

UALTSSS EIUIBITIXU THE BfrXCT' Ot OOLCinCllll C^l Tllll CMMB 
— MODCTIOKS TSIUl'ftoH — MOtiR Or Eliri;OTn(II OOtOHICOH Ol 
TUB ISUtVUT or auCT— TAS qUUTlON DIDUUSKD AS TO Rl 
LUBILITT TO OAVll HtSOUISt — DirriKEXT FUTAKATIOM OF 

coLontanK— niiiTX nuuuuMi a oodt — OBatRVATioia o> it* 

ACTIO". 

As Colchicum is a drug extensively omployod in 
the tivatioCDt of gout, and though coDdcmned by 
some, rognrded by others an worthy of being called 
ft specific for the di»ome, it will not be out of placo 
to devote a short Chapter to its consideration, and 
cndeavaur to ascertain its nal nature, and the manner 
in which its influence upon tho system, for good or 
evil, is exerted. 

Among the lutor Greek and Ambian physioians, a 
modioinc called hemiodnct)'l (^IpnalinruXos, fruin 
'Ep^iJfs Hermes or Mercarj', and i^KTvXos a finger) 
was in great repute as a remedy for arthritic diseases, 
being first mentioned by Alexander of Troles, abcnit 




h 



^ 



VALVE OP COLCHIOIM. 



U7 



the year a.d. fiSO. Paulius ^gineita, AvicCDua, Sem- 
pinn and Mcsuc, Ukowuo allude to ii 

Under tho nomo of Surugcn or honnodao^l, 
Sciapion comprelieuds tho koAxihoV and ii^iiiupov of 
Dio5coridc«, mid the IpfioidxrvKos of Piiulu«, and by 
sonio of the older writers tho hormodttctyl was colled 
aniina arttouloniin, ur the soul of tho joints. Dr. 
Fcrcira considered that tho corms brought, in modem 
tinics An^ru Oriental countries under tlio namo of 
homuxloctylii, answer to the doscription given to tho • 
ancietit Biibstaucv bearing the sumo namo, and he 
was therefore induced to beliore that tho>- were iden- 
tical, or ut least tlio underground stems of sumo 
^eoiea of colchicom, but not those of colcbicum 
autumnalc. The hormodactyls bare not been sab* 
uiittcd to the tc«t of physiological experiment in this 
countrj', though from the descriptioD of thow employed 
in tho trcntmcDt of joint affoctioDs by Paulas yl^gineta, 
it seems that in this respect they resembled our 
ordinary colclticum, for ho t^ys, "Some, iu Uio 
pannj'sms of all arthritic discosOk baro recoonc to 
piling with hennoduetyitu ; but it is to bo remarked 
Ihiit the hcrmodoctylus is had for the stomach, 
producing nau^'a and anorexia, and ought tbcrc'foro 
to ho used only in tho case of those who arc pressed 
by orgont bttsincs^ fur it rcmores rheumatism quickly 
and aftor two da)-s at most, so that they are enabled 
to resume their accustomed employment." 

The Cokbicam Automnale, or Meadow SoAxpd, has 
only been employed within the last contuiy, baring 



303 TBEATMEST OF GODT. 

been introduced ns a medicine I>y Biiron Stork, in 
1763; it is pmbiiMy the iictivc ingredient of the 
cck'brntod Eau Mi'tHcinulo, which vrtvt once employed 
about this time by M. HtL-^son, n military officer in the 
scmoe «f the King of Fraiiw?. 

Colchicmn Autumnalc belongs to tlio natural order 
MclanthaccoB, in which it is associated witli several 
other plants possessing powerfij effects on the ammol 
economy, as, for example, the Vcratrum album or 
white hellebore, the Veratrum viride, and the Asso- 
gtwa officinalis or certidilla. The corms and seed* 
are the parts mostly employed in medicine, but the 
flowers liave been oceawonally used ; when cliemically 
examined, all partd of Uic plant are found to possess a 
bitter and somewhat acrid taste, evidently depLuding 
on the prfSenoe of ft pt^ctilinr principle. 

At first, on the authority of IV-Uetit-r and Cavcntou, 
the bitter and actirc matter of colchicum vr&a sup- 
posed to bo the same as that which exists in the 
Teratrum album and ccvadilla; this, bowercr, is 
erroneous. Goiger and Heese subsequently asserted 
that they had obtained on alkaloid from the colchicum 
plant, which they named Colchicia, differing from 
veratrino in many properties, being crystalline, wlublo 
in water, alcohol, aud ctlier, bitter in tost*, but devoid 
of the irritating or sternutatory effecte possessed by 
veratrine, and giving witb nitric acid a beautiful violet 
colour, quickly changing first to indigo, then to green 
and yellow. Many chemists have endeavoured to 
obtain crj-stallised colchicia, since tho amiouncemont 



J 




TTfAL KPFECTS OF COirHICUM. 



»» 



P 



of Ociger and Hcssc, but I Tx-'licvo urithout suoocas. 
In 185S, M. Oberiin pe-esamined the subjoct, and the 
fattoiriog oro the nwulU of his invt^gation : lie was 
quite onublo to obtaiu Uic alkaloid doscribcd by Gcigcr 
and Homo, bat soparatod another substnooo, vhioh ho 
has Darned Colcliiccinc ; thii* jtrinciplo is almost in- 
mlublo in voU'T, but imliiblc in alcdiol, eUicr, and 
ehlorofonn, it in nuutral in re>totioD, and giv«a viUi 
nitric acid a beautiful %-iolet colour. 

The jihysiologiual «flVx:td ascribed to oalchicum aro 
tboM of a powerful local irritant and ocrroiu sodntirc ; 
on the lower uiimolti, moh as the dog, it causes, whou 
injected into the veins, loss of all voluntnrj* power, 
extrenio slowness of breathing, and cooEiderablu dimi- 
nution in the rapidity and force of the pulse ; Toniitiag 
and bilious purging arc sIho produci>d; the polfio 
afterwards becomes rnpid and irregular, the bivathit^ 
horriod, and d«ath onsuee. After death the mncous 
mcmbnino of tho stomach and duodenum, and other 
parts of tho intestinal canal, arc found congested 
and inflamed. Cases of poisoning in the human 
subject from oolducum ore on record, and the effects 
most uuifonnly observed are vomiting, purging, and 
tenesmus; slow, weak and often intermitting pulse; 
coldness of the extremities, aud great proetration uf 
ettcngth : courulsions and coma are seldom produnsl. 
When administered in therapeutic dose*, eulchicnm is 
oonaiderod to poesefis a considcrablo power over tlie 
accratiog and excreting fonctions, and CKpedally orcr 
(hoBO of the intestinal mucous mombranc. If the do«e 



970 



TBE.VTMEST OF GOinT* 



be large, mid frequently ropcntwl, it purges, niid not an- 
conunonly produces Daiiscii mid vomiting ; its itiflucnco 
upon the Uver is readily recognised by the appearance 
of tiie fiL-ces iind voinittd nialtcrs ; colcliicum is 
generally regarded it^ possessing a diuretic action, and 
likewise considered to niter the composition of the 
unne, incrensing tlic amount nf the solid portion, and 
more cspt-cially of urie acid and urea ; wo .sliall pre- 
sently ondeavour to ehow from the ivi^ultfl ()f our own 
inrcfltigntions, if tlieso latter Buppo-iitions be correct 

That colcliicum in its various forms has a most 
powerful influence upon the progivss of gouty inflnm- 
nintion is undeniable, and tliU action i.s not simply 
limited to the rcmovnl of gout when it attacks tho 
joints, but it prove* efficacious even in its ma^ed and 
iiTegular forms. Sir Hcniy Holland states that from 
c-sporience he can assert tliat the influence of colchi* 
cum ia striking and well defined in the chronic fonns 
of the constitutional disorder, in the peculiar ophthal- 
mia of gouty habits, in gouty bronchitis, and also in a 
class of headaches connected with tbia diatbceis. My 
own experience fully coincides with that of Sir H. 
Holland, and I would even go the length of asserting 
that we may sometimes diagnose gouty from any other 
form of inflammation, by noting the induenoe of 
colchicum upon its progress. 

Many physicians consider that it is noccRsnr>' that 
oolohicuni should pui^, in order that relief may bo 
obtained from its use ; but the opinion of those who 
haw had most experience of the remedy militates 



i 




THKRAPECTIC AOTIOJT OF COLCUICl'M. 



I 

I 



3n 



view, flS do likovi.ie my ovn obsc-rvations, 
'HUuoh prove in nddition, tliat brUk pui^inj^ prndiiced 
\iy other mcanH in not pmdtictivo of the siune beoo- 
ficial oSed. I hnvo found spoccly relief afforded by 
the use of colchieum, to pcT-ioo-s sutforing from the moat 
oscmcifttiiig pain, withont tlifi occurrfnco of any 
apprcciablo discharge.' One patient whose nttncks 
were vcr)" 8C\'<'re, and who had been accuMomed for a 
long time to take the dnig without medical advice, 
stated that id two or thrw hours after taking a two- 
draL-hm dose of colehieum n-ine, he felt himself in para- 
dise, yet no action of the bowels had been produced. 
In another iniitance wlien I ordered a drachm and a-half 
of the same preparation, without the addition of any 
other medicine, most rapid nllcriation of pain was 
experienced, >-et unattended with pui^ng or .tensibh; 
ov-ocuntion ; and n-ithin the laiit few months I hnro K<« 
four gouty patients experience similar relief from like 
dofos: in one case only vma purging indtioed, and then 
not UDtS some hour» after the pain had i<ub^ded. 

To show the inefficiency '>f simple purging in 
controlling gouty inflammation, I may mentioit tlie 
coso of a man about !)2 yenrN of age, who, at tlio time 
of admiwion into the ho«>pital. vnu euffering from his 
•oventh attack of gout, and had numerous jointA 
aSiwtcd, with a quick, full, and hard pulse, a furred 
tongue, great thirst, and hot and dn- skin. A draught 
containing two drachma <>f sulphate of magnesia and a 
Boruple of the carbonate mispeiidcd in an ounce of 
cinnamon water was administered three times a day. 




THEJtAPEimC ACTION OP OOLCHICPM. 



373 



Dr. Maetagan found thnt 20 msuois of coldiicum 
tinotiire piodaood on two occiutiuiu tlio Saving ciTcot 
on bis own puUc i^ 



KMT sBsiiiTiTiar. 




wtcmt 


owtaytnot. 


At ^ 


r.M., 


roivsr 


At 9, 


r.x.. 


P-lw 84 


.. », 






AT 


!• <> 


If 


.. 8( 


,, it. 






so 


.. 8. 


„ 


.. 78 


..11. 






7S 


.. v. 


ft 


.. 72 


.. Ill 






TO 


.,10. 


„ 


.. "W 


.. 13. 






«S 


..11. 


tt 


„ 60 


.. lit. 


*.¥., 




dC 


"1* 


II 


.. «a 



No other pliyitiologiail action was intuiifoMcrd, vnx\A 
slight »ftti«on. 

If Uie w>l« iwtioH of culchtcam depends on its itcda* 
tivo pmporty, iro should expect to find tliw drug 
cqtuiUy cfficua'otu in other inflaminator)' affections; 
now, although it po'scs^ps some controlling pwrer orcr 
inflammation which is not gout}- in character, this is 
by no moan^ well marked, and ia not at all c<iual to that 
produced by other mcdioines, as tartar emetic and 
ealoRiot ; (iufbennore these latter remedies, sn \)Ovct' 
fill in other (li«c»scfi, exert no rcry dcdded influenn 
over gouty infUunmntion. 

If the action of colcliicum cannot be explained 
either by th pur]:^tivo action of its sedative influence 
oit the vawulur Hviitein, wo arc nntamlly U'd to sock if 
ita cflwt on tbc kidtx-yn nud the urinaTy secretion iriU 
afford mj eliu) to ita modits ojtcmndi. Henoc tbe 
qnesdona nriw : Boce cnlchioum act as a diuretic P 
Uoo3 it musD the elimination of nrio acid fn>m the 
blood, or ita dcvtmctton when olroady formed ? or. 



371 



TREATMEJIT OP OOCT. 



Iiiatly, Is its influence solely exerted upon the 

in whicli tlic deposited urate of Boda bos gircn riae to 

inflammatoiy aotionf 

Dr. Christison foimd that, ttft«r giving colducom 
a patient for two daj's, the quantity of urea 
nearly doubled ; before taking the drug the urine bad 
a epccilic gravity of 1020, contained tvro per cent of 
area, and waa free from any deposit of urateii ; but, . 
during the first and second days aftt-r conunencing 
uedicbe, the uiiitc was of the densiticii 1033'G aod 
1034, wii« turbid from urate of amotoiua, and the 
second specimen yielded at loost US per oont- of urea. 
At first sight this expttrimont would appear to shov a 
marked influcDcc ofoolcbicum in increaning the oliiiii- 
nati(>n both of urea and urio aoid, but on further 
invcsti^ition a auurco of error will bo discovered. Dr. 
CbristiHon. touk Kpcoiniciu of uriiio for UDulyds, without 
refi'roiicw to tho quantit)* passed in tlio twenty-four 
bours, so tlmt, allLoii^h after tho sdniini&trBtioii of 
tile colcliicuiu, a given sample was richer in urea and 
uric acid, no proof was itfforded that tho total daily 
eliminatioD of tliu principles was augmented ; on tho 

ntrar}-, tliuy intgbt bave been decreased, for a i 
diminution in Uie quantity <^ the urinaiy 
often occuTH from tbc purgative oedon of the oolohioum. 

Dr. J. McQrigur Haclogun, who made similar 
experiments, arrived at like results, the analyses 
made on specimens of urine passed at particular til 
of the day, but there wns do attempt to shuvr tho 
daily average of these principles. 




THERAI'ECnC ACTIOS OP OOLCHlCrH. 



3;3 



I 

I 



Ax doficly ocmnected witli the eabjeot I in:ty men- 
tioQ tliat Professor ChoLius, of neldelbui:g, muda 
some experiments, tho results of vhicli nrc appa* 
reotly in favour of the idea tliat oolehicum gives relief 
by increasing tho secretion of ario ncid by the kidneys. 
He found in one case Umt the <}aantity of urio add 
wtkn m-itrly doublt^d uu llio space of twelre days^ bat 
it mtut bo rcmombcred that the dbsexrvtiiom man 
made ou a gouty subject, and one reoorering from a 
recent nttoctc of tho disevae, etrcanutances whiob 
■lono would bo nufliuient to vitiate tlie experimenta ; 
fbr during convalceconoo tlio »anio phenomenon may 
ooour without tho admiuistrution of uny medicinv. 

In oppusitiua to thcM stutomcub it ahould bo 
■k«l that Dr. Graves n-gards the power of col- 
ehieum as duo to its Icsscraing tlie fonnatioa of uric 
add in the eyiitcm, imd not to its incrcaBng its 
olimimttion by tho urine. 

I havo madu tho following olworrationA with tho 
vioir of uHwrtaiuiog tho action of colchicum upon the 
urinary secretion. 

Tlio lirst patient, a man, W. L., iigod 30, soflering 
only from a dight chronic oczomntous eruption; at 
tho timo tlio vxaminatious wore made, he was 
placed upon u rogxilatod dtot, aad tho uriuo caroEully 
ooUoctod. 

Bebn (alctng eoldueum : — 




Ott.U. OriDt, add.«n. ; <i>.(r. 1010. OtieacMlaSlfcn.-S'TScn. 

,. »i. .. « ,. .. toil -r» .. 



K«t. 1. 




f 



■»» TBEATMENT OF OOCT. 

Hot. 3. Dme CO fl. ms.; ip. gr. 101S. rrioMidin2<hn.38-19en. 

ATciagarUTlu^flS'S fl. MS. UT{ericld=8':)sts. 

Wlicn taking colcUcum : — 

JUm. 4. VtiiM,i<i6.at*.; ip. gr. IOISl UrioocU iaSlIm.-eOSi 

,. 0. .. M .. ,. lom =8-51 

,. 0. .. « ., ,. lOSO, „ „ =800 „; 

.. T. .. 68 ., ., 1018 =«-81 . 

.. 0. ., C* ,. „ 1021 =918 „ 



A*n»g«;Ur!a«vS!''3fl' <'»• 



CrieMiil=T-8T| 



The next patient wag a young roan. C. W., agod 
19, suffering from a clironio affectioE of Uifi upper lip 
(elephantiasis) ; general health pretty f,'ooJ. During 
the time thu luialj-Mcs were nmdc, the diet was uniform, 
and every prccuution t^ikcu to sccuro luxumcy in ths 
results. 

Before taking colcliioum ; — 

Jan. IS. 18S4. Urid^ CC{L dzl: Ep, gr. lOlT. UriendUl -q. ,,„ 

ta 2( in. -'*»«>* 



II. 

IS. 



S8 
80 



kTttage : Urini^ 3?-; fl. on. 



1027. 


= *■« „ 


1037. 


„ =8 00 „ 




IMe tdd=S'i>3 gra. 



When tttkiDg colcliicum (half a fluid drachm three 
tames a day). 

J*n.l6.ie£4. UTino.Cfl. (in.:«p.sr.1018. Uricacidi .... 



t» 


18. .. 


M S3 „ 




». 


1034. 


>> 


=T-M .. 


»> 


IB. „ 


.. St .. 




•f 


loss. 


tt 


-7-24 ,1 


II 


so. ,. 


.. 13 ,. 




1* 


1031. 


>■ 


sS-00 ,1 


<» 


a. .. 


.. 18 .. 




II 


1037. 


■1 


-s « „ 




ATtnoB 


CriiKv 28-3 fl. 


oai 






Urie aoid, 5 '26 gn. 



THERAPEITIC ACTIOK OF COI^HlCi™. 



a:T 



Tb» ooltihtcum yra6 taken throe tiincs o day for two 
in^i oo the oocatTonoo of purging, ono doee was 
omitted ; the two doses each duy vcrc sufficJcot to 
keep up a free nction of the buwvls. 



W 



The third ca.*c, n gouty man, B.F., vho during five 
days, whcD not taking any rnvdiciiio, passed tlio ful< 
towing anooDts of uric ncid : 1*30 graiui, 1*95 groins, 
2'73 grainn, 2'14 graiu-s and 3"05 grains. Colchicnm 
wino was aiWurards ndininiiitercd in half drachm 
dofes three tiinm n day, coinbin(Ki with caloncd mag- 
nesia, and was almost immcdiatoly followed l>y a 
markod improvcnioiit in th« aflvct«.-d joints. 

Under colctiicum :^ 

Jto. so. 1S53. VnM, 43 A. oubom; *p. p- l^ll. Add. 
Vric i(id ia th< 34 hoiin=3 SH fnlu. 
,1 91. 1, DUnhiFit fiom mcdlciaa ouuid titt tarn of uiidi 

„ S2. „ Vtio*, 35IL oosM*; «p. tr. 1011 Add. 
Tru add in lii« S4 hmn^S'SS fnuat. 
n S3. „ Crio^ 47 fl. eaant: ip. ft. lOlt. Ad4 
DrltMid in tlt«34 liaan»S'99(run>. 
On Ibe SIM, \ht j«tl«iii took bnt two dead ol t^ nudioak. 
On lh« aind, b«i not, •ul diMOMianiid iL 
Jh. S«. lUa. Crint. 74 a. oodchi wf. p. 1011. Acad. 
Uikaeld In the S4 havn^t-VJ (nJM. 
■( !7. „ Crin^ Sfl <. eaatm; *p. p. 1011. AaU. 
Cri« UM in Itw S4 bmn-liM pain. 

Befon< takbg coldiicuro : — 

Attr^ataouattf Brio add yawed In Ihs !l baan<*9'S (O^ 

When taking eolduoam :— 

A*trag« amomt «l orie add puaad in 34 kom S'4I |nib«. 



t7i 



TREATMENT OF QOCT. 



C. F., a male pntient, oD half extra full diot, 
8iiffi.TUig from iiuy vciy aulivc pjTiiiitouis, but liitving 
ft liirgv ubso.'^ disdiurging urate of twda and pus. 

Under the influence of colchk'uin : — 



0. 

„ 8. 
.. 9. 



41 
U 
87 
IS 



gr.1013. DriaMidiD3IIir«, = 0'G8Kn. 



1013. 
1013. 

1013. 
1011. 
1011. 



» 
It 



= 0-09 „ 
-OOO ,. 
= 0-14 .. 
= 00 „ 
=0-00 .. 



Tlic diet the sitme, but without culohiuuni : — ■ 

Ju.10. Urina, 4t 11. on.; up. gr. 1012. UrlcaeiJIu2ilm. = 0'7~^gn. 

»n. .. 8* .. ,. lOU =085.. 

.,12. ., 01 .. „ 1018. „ ,. -Mt .. 
„ 18. „ 85 „ „ lOU. „ „ =000 ., 

.,14. .. 87 „ „ 1MB. „ „ =0-00 „ 

The ftverages bcasg — 

Dsdtr aaldtionm. VtitM, tS'i (1. ou.; nrio a«id=0'I3 gn, 
WitlioiU mtdioiiis. „ BBS „ „ =(I-SZ ,, 

J. L., a male, aged 57, bus had several attacks of 
gout ; a year or m«re geucrftlly olap«a between codi ; 
for Uie fiisl few years tlio ball nf the groat toe only 
was affected, but tlie discftso nft^.T\vards travelled 
1ipvard». No deposits uf unite of suda vitdbtc. 
During the time that the joints wire severely dfectcd 
the uriuo was sccuity and high coluurod, gi^'iIlg rise t» 
B„i-ed sediment of urfttc«. At the time the quanlitativo 
analyses woro commenced the patient was sufTering 
from slight affection of the joints not accompanied 
with febrile dittorbaace. 



i 



THEllArKUTIC ACTIOS OF COLCHICUM. 



tA. 1. Ur!n«, 205 fl. eiinnM ; np. gr. 1031, >t fiO' Vtii. Omt. 
Vni pHBfil in the 31 baun= !13 grslna. 

8. Urine, SS fl. ooooc* ; (p. gr. 1020 5, at GO* F>b. 
Crta pMMil in tbc 21 boiuvB IBB gruni. 

Crle acLiI, • Cov crjMaU, too smnll ta oiltcct ud weigh. 

9. Uiian, 37 d. onuiMt; ip. gr. 2019, at £0* Pah, 
Ur<»[>UM>l in ibtf 'ithaun = ^i9 gniiaa. 
l/iic aokl, oulf a foar lalctoicaiilij ctrilab. 




97» 



tlio iiifluoncc of colchicum : — 

F«b. 10. Driiu), SS fl. ouiicm; *p. gr. IflIP, At 00* F*h. 

DrcB puwd ill tlio £1 lionnsSOB gniiUt 

DHo acl<l, a qiuolltjr tuo niinDtc (o collMit. 
U. C^in^ VI d. uuDCM ; ip. gr. 1021, at Co* Pah. 

Cm in the 34 h«ur* = U4l iraiaa. 

Drio acid in mlctoMioiHe i|uantjli« odIj. 
IS. Crlnc, 41 fl. ooimcb; >p. p. 1010, atflO* Fah. 

Dnapauallnthe2< hoan-2;o. 

Uric acid, a time* ooly. 
13. DriiUk 38 fl. ooeuim ; ip. (i. lOlT'f at AO* Fab, 

Vn* latJ b tlM 2< bonta^SlI Gtaiiu. 

Crj« add, a tm; fair erTitali, too idiall to Boll4«t. 
„ It. Vtiaa. 33 6. uuMta; *p. sr- 10:!rS, u 04* Tab. 

Dm pwatd in tlx SI houn= SSt gnini. 

Dm wld. a tnfc 

Tlio patient omitted colohicum at tlio lost dutc, a.<t 
some feeling of fatntikess was indoocd b^ its luc 

F«L IS. Drios 3I> 1 ooDoea ; >p, cr. 1030. at 80* Fak. 

DrM ptMcd in Uie 34 boun-IOl gnuiu, 
„ 19. CiM SOU. ouMw; Ip. ST. lUSO, •tWFkfa. 

Prty>— Hatbe24h«Bn = 201 gtriiUL 
H M. 0riM,42fl.odaoM; ip-cr. IOIT-S,al«0*F»b. 

Dna |iMMd ia tbt 24 bo»« = UI gnlni. 
„ SI. OriiUv SI d- oubom: ip. gr. 1014'S, at 00' Fab. 

OrM jiaMtd in ths 34 k»in - 3J-i gnia*. 

V« wyihh of onQ kU precifaUtcJ bjr lb* addllion of 
bydnabLnTie add. 



8» TREATMENT OF GOIT. 

Veb. 22. Crine, S< 0. oiiiiMa; ip. gt. lnl3'5, nt 00* TtSi. 
Vna fuatd in the 3 1 liont>« SAO gndnt. 

Average before taking medicine : — 

Quiotit; oF urine loniid in tho 21 haiin = 3D'S fl. oanctt. 
Amuaat of arm „ „ =3'23'tlgnu]i. 

Ai-orage during tlic nilininifjtration of colcliicum : — ] 

Qantit; or urtnc luumd in the SI l)[)i]Ti=3fl'B S. ^tmett. 
Ameunt of urea „ „ — 2<l gniiiii. 

Average after omitting the iise of tlie colchicum : — 

Qiuatttx of aria« pntMtil la Itio !t boan= 41 '1 11. onBoes. 

AmountufuDA „ „ ^33S'4 gnius. 

The amount of uric odd was iu do iostancc mifBdcDt 
to collect and weigh. 



H. 0., a male, agotl 51. Had suffered from many 
attacks of gout, but was not labouring under any 
ncuto affection at the time the urine was exauiiiicd. 

Urino before tlie administration of colehicum : — 

IToT.Sfi. Orlae,SSfl,ou,;ap.gr.lO0S. 0Tleuldlnthe2<liiiL = 1-B(lgnt. 
.,89. „ n „ .. !01S. „ ,. =a-ia„ 

,. SI. „ Sa „ ,. im =3-72 „ 

..28. „ 00 „ „ JOl*. .. „ =300,, 

Under colehicum (twenty minims of tho winu three 
times a day) :— 

Kor.SO. CTla«,efil!.on.;flp.'cr.1Dll. 1Trio>^iBl^2(hi«. = l-Slgn. 

» 8". .. « .. .. lOlS- .. » =3-20,, 

I>«. 1. „ e* .. „ 1018. „ „ =2-18.. 

„ a. „ "2 „ „ looa. „ „ =i-8«„ 

Avonigc before taking medicine : — 

Qumstitr, 74-Sa.«H.; ario«ciilpBM«diiitbtSlhoun=>fi-70gM!ai. 



TflEIUPELTIC ACTIOS OF COLCUICUM. 



SSI 



Average when taking colclitcinu ; — 

Quotlt}, OT'E 11. rat., nrlo&dil {>ih»1 lu llieS4 boDtist-SSfn. 



The eubjoincd aiiiLlj-sct), 71 iu number, vcre made 

oa tlio unao of « mitio puticut, H. C, 51 years 

of Age, who wti^ niliitUU'il into the hospitul in 

Nowmlwr, lS'y2, sufToriiig fi"um chronic bronchitis, 

[kccompitiiiL'd with much diffimilty of breathing: in a 

liort time Uio symptoms were reliovod in a very 

iog maiinur «ii tho occunvnco of u severe attack 

gout in the bull (if tlto groat toci which afterwords 

bxtonded to tho side of the foot and kaee. About 

[five weeks ufler, oa readuiission for another attack 

[of bronchitis, tlio oxamlnationa of the urine were 

\ commoncod, tho patient at tho time ha\'ing flying 

1 0outj' pains iu many joints. Tho results, including 

tlio amount »f urino puwd MOh day, its 

grarit}', and the daily elimination of urio acid, QIus-'' 

[ trate woU the dL'ipositioa which the kidneys appear to 

kaoqnire in gout of throwing out the add in an irregular 

nud intennittcnt manner. In the present case tlio 

daily amount of this prinoijJe was sometimes as much 

as eight grains, sometimes as little as two-tenths of a 

grain. As oolchicom was administcied during a part 

: of the time, any iuftuence it might have in alterbgthe 

iuaoant of uric acid would bo shown, and it appears 

I {ram thoae results, that it diminished rather tlian 

increased its excretion, thus oouflnuiiig the conclusion 

at which we bad previously arrived. The average of 

the uria acid during tho whole time tho patioot was 



K L 


— BCBI 


^^pps 


333 


TREATIIENT OF GOUT. ^H 


under the drug being I'G-J grain 


, vlicreas irhen d^^l 


^ taking 


colcliicum it tras 2*36 grains. M 


Date. 




ISSl. 






n«T. 35 


»8II. (o. lOOS l-9Sgn. 


No MolidML 


„ sa 


72 „ lOlS 3-13 ,. 


. 


.. IT 


as „ 1011 a-71 „ 


At«^ Dtmk act J pMMd 


.. 94 


eo „ 10135 sou „ 


ptt i,\mi''i'70 gn. 


.. 39 


83 „ 1010 1-Sl „ 


Vinam ColchM, M. ii. 


„ SO 


Bd „ 1011-5 3-sa „ 


taUdi*. 


&M. 1 


a< „ ICll'S 9-13 „ 




.. s 


73 „ 1007 0-M „ 


Avtneaof BH«Md(1pM««U 


s 


ee „ ion on „ 


|i«rdiMii — l'39gr. 


■■ * 


«S „ lOlO I-IJ „ ^ 




» d 


«t „ 1010 0-04 „ 


TiawB OoleUd, It Kxx. 


.. 


w „ io:a-c i-7i> „ 


Iwln^. 


.. 7 


7B „ 1010 1-T7 ,. 




.. S 


73 „ 1011 0-4S .. 


^1 


.■ 


70 „ ion ot; „ 


^^^1 


„ 10 


4d „ 1013 1-S8 „ 


^^^1 


» 11 


to „ inlO-£ 1-00 „ 


ATcn|cori>Tie*riilpw*«d ■ 


.. 13 


47 „ 10H5 ssa ,, / 


ptr dim 1-27 gr. fl 


.. IS 


49 „ 1013 1-65 .. 


1 


>■ I* 


87 „ inu 1-85 „ 




„ IS 


61 „ lOOD'O 1-03 .. 


^^^1 


„ 10 


45 „ 1010 O'Sn „ 


^^^1 


>t 11 


87 „ lOU-5 1J6 ,. 


^^^1 


„ IS 


54 „ 1007 0-27 „ 


^^^1 


t. 1» 


40 „ 1010 0-15 ,. 


^^H 


„ 20 


fi7 „ 1009 0-19 „ 


^^^H 


.. 21 


61 „ 1015 Sti „ 


No acdicBiie. ^^^| 


.■ S3 


6S „ 1013 1-81 .. 


^^^^ 


II 33 


4D „ 1010 0-ea „ 


^^^M 


•I '* 


as „ 1013 1-75 „ 


^^^M 


„ 55 


49 „ 1011-B ♦■« „ 


^^^M 


•. ss 


04 „ 1008 OSl „ 


^^^M 


•• « 


4! „ 1010 om „ 


^^^M 


n SB 


01 „ 1013 1-32 „ 


\ 









HIH 


^^^^^^^^^^^^^^^g^^^^^^^M 




^p 




^^^^1 


TO7.RAPECTIC ACTION OT COimiCCM. S8» V 


^^^ 


*™""/'"l UfaoriJpa— i orcuTTiHmt^ Boa »l«l. 1 


^H 


lb* taVu. M bdun, >^ ^^H 


^P iscs. 


^^1 


DtA. 3S 


SiO. UL lOlS O-flOp^ ^ 


^^H 


„ 80 


« „ I016-B 0<J „ 


^^1 


.. SI 


40 „ 10)3 0-40 ., 


■ 


1893. 




^^B 


3m. 1 


M „ 1015 013 „ 


^^M 


.. s 


W „ 1013-5 407 „ 


^^^^^ 


.. 8 


70 „ lOU-9 403 „ 


^^^^M 


.. * 


CI „ 1012 s-es „ 


^^^H 


" •* 


SO „ 1011 S-09 „ 


^^H 


^ ,. 


01 „ 1010 1-33 „ 


^^^^M 


■ » 


48 „ lOll-S 2-00 „ 


Ifo SKdicine. ^^^^^H 


■ » 8 


18 „ 1011 8-37 „ 


^^^^1 


■ .. 


6B „ 1011 '5 S'S( „ 


^^^^1 


■ 


65 „ 1000 0-18 „ 


^^^1 


■ 


11 „ 1030 3-10 „ 


^^1 


■ 


SB „ lOlS-S 3-00 „ 


^^1 


■ .. 


*8 „ 10)3 S«0 „ 


^^1 


.. 1* 


*7 „ J01S5 SO* ,. 


^^H 


.. Ifi 


83 „ 1011-8 S'53 „ 


^^H 


.. w 


4> „ lOJl-S 330 „ 


^^1 


.. " 


SS „ 1011-9 5-40 „ ^ 


^^H 


„ 18 


S3 „ 1010-5 8-SO „ ' 


Tlnam OolAl^ Jw Ur ^^H 


.. " 


24 „ 1022 8«0 „ 


la41t. ^H 


, .. SO 


21 ,. I0!3 6-70 „ 


^^1 


M 


SO „ 1012 COO „ 


^^H 


■ 


37 „ 1008 I'CS .. 


^^^H 


.. s> 


M „ 1007-6 1-40 „ 


ATenetaTnrloMidpMNJ ^^H 


.. « 


45 ,. 1011 3*5 „ 


ptrdicm^SO'OSpi. ^^H 


.. w 


At „ 100)1-6 0-62 ., 


^^1 


L ,. M 


80 „ 1010 9-00 „ 


^^1 


■ .. » 


69 „ lOlOfi I-M „ . 


^^1 


■ .. « 


6T „ UH-5 4-37 „ 


^^1 


■ » U 


60 ,. toil 1-17 ,. 


^^1 


■ 


63 „ 1012 0-97 „ 


RantdklB*. ^^| 


■ >. 


35 ,, 1907 mAiaUf 


■ 


\ f*^ 1 


U „ 1«13 0-76 fim, 


1 


.. t 


87 „ 1013 S-4< „ 


^m 


^^H." ' 


4« „ 1011 l-«l „ 


m 



I 




3S1 TBR.VTMEST OF GOUT. 

Trio acid passed iu 24 hours : — 

SUiimum of nric nold S'lIO jjn. 

Micliuuia O'lS ,, 

AraiagD 1-S3 „ 

Aitragp ttilbiint eolsbiiniiii • • . . • S'W „ 

Atemgc undet mlehieam I'OS ,, 

Quantity aud specific gninty of nriue ; — 

jLitnge quuitllf of urlno psMcil witboiit 

<»1dIuo(iio ...... £1 II, ua. 

Specific fftatitr 10I3-S „ 

Adcir*^ qnootltf nndet Mlclitcnm . . SI „ 

Spotiific yrarltf 1011-4 „ 

Hexultn of <inal!/s6s.~~Th6 result.^ of thaw oh«cr\-a- 
tioiut on the action of colchicum may ho thus tnimmed 
u[i. Ill CiufC I, where iioiUrt Ronty afiMtiou nor 
febrile diaturbunoi; exUtcd, colchiouni appeared to 
have the effect of slightly diminii^hiug the quantity of 
uriuc and likewise of decreeing ttie excrctioa of 
wrio acid. 

In C[isc 2, where the circumstances were amilar, 
the influence of tho medicine iippeared to he a notable 
diminution of the quantity of urine, the amount of 
uric acid being a httic augmented. Tliit increase, 
however, wii.< less than a quarter of a grain, and might 
arise, at luist in part, from the circumstaneo that uric 
acid is to some extent soluble in water, and therefore, 
when the urinary excretion ia large, a portion may 
escape precipitation. 

In Case 3, a gout}' man recovering from an acute 
attack, the amount of uric acid wiis somewhat in- 
creased, but not more than frequently occurs tn 




TUEnAPKtTTlC ACTION OF COLCUICUM. 



aes 



patients tmder like circumstances, where no medicdiw 
is administered. 

In Case 4, the colohicum oppearod to cause a 
decrease both of the urine and uric acid. 

In Cose 5, when the examinations wore made both 
bdbre and after the administratiou of the colohicum, 
M mIbo durini; the time the patient was taking tlic 
dru^ the amount of urio acid appeared to remiiin 
about the same, but was extremely small throughout. 
TiiB urea was sliglitly au^ented during the action of 
the medinine. The quantity of the urine was also 
larger, but little stiois can be laid upon the fact, as it 
ootttinaed to inorcafie still more after the drag was 
disoomtinned. 

In Oose 0, the excretion of uric a«id became much 
Iwfr lUid the quunlity of urine aUo smaller; but in 
patient's urino considcniblo rariiitions wvro ob- 
•erred, many of tliem totiilly imcpoctiTo of tbc 
aotioo of r«mcdie8, a circumstance which rcnden the 
figai«s lev valuable. 

In Case H, we find tliat the amount of urine was 
thv same when the patient was taking colchicum as 
when no drug was giren ; but the quantity of uric 
aoid was notably dintint.slicd during its administratioii. 

Besides tlie rc^ntlt^ wc havo just detailed, we haTo, 
in the chapter on the urine, gtTen scrreral other 
analyaes, allowing tltc tnBuenoc of colchieom upon the 
urinary aecretiuufl. Tlius, among the oases of acoto 
gout, we find the patient (Case 4) was under Uio 
marked tnfloenoo of colchioom on the 10th and 20tb 

e 



3$S 



TREATMENT OF OOUT. 



of Ppbruarj', and the peculiarity of the urino con- 
sisted in its containing a very small mmjuut of urio 
acid, compared with that present during tho time the 
inflammation was severe. In Case 5, colchicum was 
given during the whole coureo of tho attack, but as 
the dose van rather small, aud the man bad been long 
accustomed to its administration, tho daily altcrutiou 
of Uio uric acid probably depended rather upon tho 
different phases of the disease than tho influcnco of 
the drug. Among the patients suffering from chronic 
gout it will bo 8cen that in Cose 11 colchicum was 
administered with tlio apparent effect of diminishing 
the excretion both of urio acid and urea. 

From a general review of the results obtained in 
the preceding analyses, wo are compelled to draw the 
following conclusions, 

Fir»t. There is no evidence that colchicum produces 
any of its effects upon the system by causbg tho 
kidneys to eliminate an increased quantity of uric acid ; 
in fact, when the drug is cuntinned for any Icngtbened 
time, it appears to exert a coutniry effect. 

Secoiidlif. "We cannot assort that colchicum has any 
influcnco upon the excretion of urea, or tie otlicr solid 
ingredients of the urine. 

Third/;/. Colchicum does not act us a diuretic in all 
oasea ; on the contrary, it often diminishes the quan- 
tity of urine, more especially when it produces a 
marked effect upon the alimentary canal. 

Dr. Chrifiti.ion's observations would probably have 
agreed with many of my o\^^l, had I taken for analysis 



I 



i 



THERArEUTlC ACTION OF COIjCRICCfM. 



3(t7 



portions only of tlio dnily urine, for Case 2 miglit 
have bcea made to eliow Uiut Die uric acid was more 
doubled by tho remedy, ultbougb in leolify 

' tbere was do iiicrcuM; in tho daily vliminution. I am 
therefore inclined to Ihink, that the »liiU'menU rcla- 
tire to tho iucrcase of uric acid from the vxliibitiou of 
oolohicum have arisen either from the diseoso liaviag 
become altered id phaso during the examinatiuii^, or 
that erroneous deductions have l>eoii drawn from tho 
analj'ses having been confined to portions only of tho 
doily urine. 

As tho operation of colducum can neither be ex- 
plained by its pui^dvc effects, nor by its power of 
altering the character of the blood and urine, its real 
mode of action Li still a subject for inquin*, and veil 

I Vortliy tho attention of the tlicrapeutist. Some hare 

FiDggGsted that it may act oa tlic nervouR fystem iis a 
iedative, but such an cxptuMtion is of m gtiuTfi] a 
or that it applicA to many drugs bc»idi.'S colchi* 

*eunu OUten have intngined tliat its power ia duo to 
the influence whidi it exerts on tlio peculiar struotura 
implicated in gouty iDflammatioD, namely the tign* 
mentous and caitilagiDOos tiisuca ; this may possibly 
be oorrect, for we know that certaia oodatirea oootnl 
tiiO boarti or ocntnl oigau of tho circulating cj-ftcm, 
oUwHt ttio cnpillariea or extreme portions, and it may 
I that thoM tissues, of which the vitality in low, am 

'pecoliarly affected by tho drug in qucsticHi, Should 
this bo tho cose, wc Khuuhl natonlly expect to find 
inflommatioQ of tho sumo tissues, when not of a goaty 

COS 



TREATMKXT OF GOUT. 



diarftotcr, controllable by miMins of CDlobicam, an 
that gouty sjinptoms whiii not coniicctod witb such 
infUininiation, ano not so iuflucncod; but bi^forc thu 
subject can be considered definitely settled, much 
further cliBioal experience is needed; thero are, it 
is true, many obstacles in the inquiry, and n-it the 
least of these is the difficulty «f positively ascertaining 
if^ in our comparative trials, the affected tissues ere 
alwavs tbe same. 

Although colchicum may possess wime power OTer 
rheumatic inflammation, it assuredly does not exert 
the specific action exhibited in caaos of true gout, but 
it may be argued tliiit tlte structures a9ect«d in tlio 
two discasea nro not proei.'*i.-Iy the Bniae. 

It is asserted by some tlmt colchicum possesses the 
power of rendering the nrinc neutral, or cTOn iilkaline : 
that such is not an iuvuriiiblo effect my own obeorva- 
tions i)n)ve, but as the esamiuations wore all made on 
the whole day's urine, which rapidly changes after its 
secretion, the amount of ilii^ iufiueuco was not ascer- 
tained. 

Without nttomptiug at present to explain how 
colchtcum acts in controlling gouty indammntion, I 
shall content mjself in assertinj; that it does so in a 
most marked degree ; a fact placed beyond doubt by 
the evidence already adduced, and which could be 
strengthened, if necessary, by further proof, especially 
by the fact that sufferers from gout often talce eolchi- 
cum, not oidy without consulting their medical adviseis, 
hut even contrary' to their injunctions. 



TRBRiPEUnC ACTION OF COLCHiarjf. 



3sa 



The great popularity of thu different quack prepara- 
tionfli such as tlio £au M^diciiiato, Wihon'ii Tincture, 
and Kcjuolds' <Sp(«ific, all of wbich owo their efficacy 
to tho colchicum Uicy oontnin, ])i>iut t^ the same oon- 
cIuMon; and I believe we may safely assert, that 
colchicum poacflEes as epc-cific a control over tnie 
gouty influinmatiou as ciucbona barks ovi-r intermit- 
tent fever. The c^-tdenco hitherto adduced of thu 
power of c>Ichicuai in allcmtiug the uigcatiymptoiae 
of gout, haD not in auy way ptxived that it loay uot be 
iiijuritms iu its after-^-fficts, and tho detenuiuutiun of 
tbjj point is fraught with ioterest. Sir C. 8cudaiiiort^ 
in alluding to the £au M«!dicinalc, of wliich ho had 
ofteti wituf.'SHud the dfivtH, n-marked tliiit it hiid lH>eti 
the fruitful source of many cases of chronic gout, by 
oniecbUng the nervous sj'stem, and occasioning a 
degree of despondency and languor never before expe- 
rienced ; he furthermore asserted, that he had found 
no cases of ^out so tedious and intractable as thoao 
which had been tlius empirically treated. 

KotwithstandiDg these remarks with regard to tho 
Eau U^cinale, Sir 0. Scudamore was iu tho constsot 
habit of prescribing colchicum, and has stated in some 
of his writings, that it must be admitted to bo a 
Tuluabk) medicine by all who hod sufficient oppottuaity 
of putting its merits to the Ux^ 

Otltcr ph}'Hici!uis have also ezpreeaed themselves 
strongly on the subjc-ct of the injurious efleofs of oolchi- 
oum ; for example, Dr. Petit had an idea that it cauncd 
gouty attacks to bvcomo more frequent and chronic, and 



«M 



TREATMENT OF GOUT. 



Dr. Todd in his clinical lectures expresses & similar 
opinion, for Iio remarks, that although culchicum. 
ehortens the duration of thp,fits, it also diminishes the 
inteiTal between the attacks, and that the Hystem get* 
accu.«tt>in<xl to its use &s it doeo to opium, and there* 
fore thi' ilnsp must he increased in flrd^-r to keep up 
tlie cffi-ct. It is curioxis to find that I'aulus iEgineta, 
in reference to the use of hermodact)'1un in gout, aavH, 
tha;t although it generally removes the symptomn 
irithin two days, it injures the stomach and piodnces 
loss of Hppetito, and (Jirml^l tliorcfnro bo used only by 
Uioso who are engaged in urgent business. 

Id antagonism to tlic«c authoritieB, thero arc man] 
pbwiciiins of the highest eminence who regard colchi-' 
cum as a ri-mcdy of tho iitmti»t value in the Irontmont 
of the varitsJ munifi^tntions of gout ; among these I 
mny mention Dr. ■SN'iitsou, who, in his Lectures on 
tho Priictice of Physio expresses himself very decidedly 
on tlie subject. With regard to the ucute paroxysm, 
he remarks that colchicum, judiciously given, may be 
fairly accounted a specific ; and again, " This drug has 
certainly Uie property of easing, in iin almost magiciil 
manner, the pain of gout. How it operates is nut so 
clear. It is apt to prodiieo nauf^ea, faintness, and 
diftrrhoMi ; but its curative inflneuee is not eouditiouul 
upon the occurrence of these symptoms. Sometimes 
tho rapid disappearance of the gouty inflammation is 
its only perceptible effect The patient may be 
helpless agony mth a tumefied red-hot joint, to-day ; 
and walking about, quite well, to-morrow. The colchi- 



TUKUAPELTIC Af.TION OF COLCHICDJL 



891 



eum ia, tbcrefore, pUinly an anodyne." And u to 
ita Dso in the moro chronic forms, tho samo author 
obMlTCs, " I apprehend tho proper way to oradicnto 
(be lurking imdue of the mifchicf is to coatinue to 
giro Bmall doMS of tho coluhtcum ; 6vo mtnims of tho 
wine, for instanoc. two or throo times a day for a 
while." And liutly, thnt ho looks upon it4 propor 
nse in tlto int«rviik us likdy to be attended with 
beneScial efTocii, will bo evident from the following 
passage : — " As I tliink that the dregs, if I may so 
speak, left Leliiud it by a gouty paroxysm, may bo 
di^rsed by tho continued use of what, in the usual 
acooptatioin of the word, I may call alt4>ratiro doses of 
oolohicum (doses, that is, which produw tho desired 
purpose gradually, and by inscnsiblo operation), so I 
think it probaMc thiit niuny a tit of the gout might be 
averted, if tlu i tu. iy wen.* giraa in tho mbu) vaj 
Qpon the first oocunvuce of the ordinary premonitory 
tnmblefl." 

Although 1 r<>[|{. .. tliat a still more searching 
inrcstigatioD, not only of the mode in whicli tlio action 
of cotchicum is produced, but likewise as to the real 
efieots of the remedy under different circumstances, 
u a deoderatum, and one, I trust to be enabled odb 
day to unravel — still, as tho result of long-continued 
observation, I am (tf opinion that the following propo- 
ntioos oaa bo establisbed with regard to it. and may 
bo acted upon with eaSetj. 



Urtt, in aeuU gout. — Colchioum has a spcciSo power 



a» 



TREATMENT OF OOOT, 



orer true gouty articular iiiflamniation, and may be 
given v/iiii atlvantagc under suuh circumstanoes. It 
soldom fttils tti allay quickly nil inflaiiimutory symp- 
toms, witliout the UL'CTJSsary [iroductioa of «ny sensible 
pliy^iological effect. 

If cathartic action ho requii-ed iu gouty caaea, it is 
better to combine some a[>erieut mtb the colchicmn, 
and not to tniet to the influence of the latter drug, 
for when mucb purging and Tomitbg result from the 
colobicum, nci-vous and vascular depression likewise 
follows. 

It is of advantagD to give a full dose of colchicum 
nt the commcncemi.iiit of tbo treatment ; for oxample, 
Lalf a dnuJim to n ib-aclim iir more of the wine, and 
to follow it up by smaller dose^, as troni t^n to twenty 
minims two or thr(w times a day, ciirefully watching 
its effect on tho pulse, and nivtr allDwing the pro- 
duction of sickness or depression. 

Colchicum, when injudiciously administered, gives, 
rise not only (o nnusca, vomiting, and extreme depre^^H 
Mon, but occa^aooally to u v«ry obstinate and peculiar^ 
kind of diarrhoea. 

MTien great depression U produced by colchicum, 
gout ie apt to recur soon after tlie patient lias rallied 
from the effects of the drug- 
In ucute gouty cases the iuffuence of colchicum 
should be continued in a mild and gradually diminish- 
ing degree for several days after the inflammation has 
subsided. 

liVhen oolchicum i» carefully prescribed, it haa no 



i 




TI]£RAPEtniL- ACTIOS OF COLCHICTM. 8«8 

tmdsDcy to hasea tbe interrala between the gootjr 
puroxjons or to render tho diaeoso ctironic in 
duira«ter. 

Sfcondly, in cArottic gout. — Colchicum may be ad- 
vantageously giren m the cxacerbatioiis of chronio 
gout, but this (iliould bo done witli great care, ns there 
u Ictt occasiua to alleviate paui, and tbe patieot is 
gcncruUy not so able to bear a lowtiing treatment ; at 
tbe Nuno time, it must be rcniL'iiibtTvd tliat those who 
luiro taken colcbicum for a U-ngtlu.iK'd pcriud ucquirv 
a oeitain toleiaiico of the drug, a circumtitance to bo 
ocaiidorcd in apportiouin]; the dose. 

nirttly, m ihe inttreai» letireen QUtKk$ (^ gout. 
— There is some evidence aod cousideiuUo autbarit>' 
for regarding colcbicum as effectual in narding off an 
attack of gout ; espccialty <n-heD an approaching fit is 
bogbning to manifest itself. 

Cokhivum may often bo given with advunlagc to 
gout>- Rtbji'cts as a cholugoguo in lieu <^ tho prepara- 
tions of mercury. 

Vaiue lif d\ffcreni prrparattottt of CoMicum.—^TiM 
last question in relation to colchicum that requires 
dimnesioo refers to tho preparations best suited for 
emplo)'ment, and upon this subject it is well that 
I should make a few oWirvations. Whether the 
power of colchicum be doc to its containing an alkaloid, 
u itatcd by Qeiger and IIc«so, or a nvutral cr]'staUinc 



m 



TREATSIENT OF OOCT. 



body, BA asserted by Oberlin, it is 8 matter of the 
Lig1ic«t probability that tho same active principle 
pervades the whole plaut, so that whether tlie pow- 
dered conn, or its wiac or extraot, or the tincture of 
the seeds or flowers bo made use of, the very samo 
rfmedy is \-irtually adminiaterei This fact being 
vstublisliod, much of the discussion regarding tixo 
relatire virtues of tho diffcrt-iit prcpurations of the 
plant, although of hif;h importanuo to tlic pharmiwo- 
polist, will powc-w but little intort-st to the therapeutist. 
It will be fotmd, when watt-hing the practiw nf those 
best able to judge of tho oScots of rcmcdioB, that one 
physician employs a preparation of the eorm, aiiotlior 
of the socdx, and a third of the flowers, and nil arc 
fiiUy satisfied with tho effects obtained ; ultliough it u 
true that some of tho preparations arc more powerful, 
doso for dose, than others, yet the diflerence is easily 
csplainod from the (juantities of the drug made uso 
of in their formation, as well as from the vai'jing 
trtrengtlis of the difi'erent parts of tho plant. 

I haw frequently prescribed with good and uniform 
effect an amorphous form of colchicia obtained from 
Germany, and the dose which has hcon found to 
answer host has varied from a thirtieth to u flftoenth 
of a grain, dissolved either in water or some aromatic 
vehicle. The only objection to its use is the nb^euoo 
of crystallisation, and I should feel much interc!*t in 
substituting M. Oborlin's crystalline neutral principle, 
which, US appears from its chemical re-actions to be 
contain^ in the amorphous colchicia. In mailing 




THERAPKITIC ACTION OF COLCUICUM. 



395 



OBe of micli a preparation wo might fed assured 
that wo wiTL- jiriwribing tho druj; in dclinit« doses, 
witlifiut feftr of tho iictivity being influoncctl bysouon, 
BoU, or any of thi> other circuniatanccK which arc 
liable to oau8o considemble alteration io the strength 
of th« galenical oompounda. 

The preparations of colchioum which I have been 
oommonly in the habit of emploj-ing are the wine and 
Hie BOetic extract of the conn : the first is an adrao- 
tageooa form when the medicine is given as a draught, 
tho Bocond when it is aJmiuUterod as a pill, 

I am fully pentuiidud thut all tho good cffoots 
dcrivublc from the plant cikn bo obtained frum thcao 
two propuTutiiins, still otliors may at timoa bo adran- 
tagootuly preecribod, as tho nmplu aiid innmoniatcd 
tiltctnToa of tho Bocds : tho litttor i.t u'seful when it is 
dcnnible to combine a vuscalnr ittimulant. 

Most of tho prepuratinns have had their advocates; 
tlio acetic extract was introduoed and iavoorably 
reported upon by Sir C. Scadanu»e, who oonaideced it 
toildcr in its action than any otltcr fwnn, from tho 
acetic acid exerting a modifying power over tho 
active principle. It may, however, be n^arded as a 
fiwt, that all tlie effects of the drug can be obtained 
from the proper adminUtration of any ono of ita 
galenical formti, but it must be home in mind that 
some are macli more a<:ti\'e than others. 

A mode of giving coldiicum, commonly cmplo)'cd, 
and answering more than ono iodioation, is to proacribo 
a draught contjiining colchioum wine, the carbonato 




390 TBEATITEST OF OOUT 

ntul sulpluito of niHgnc^n, mid some aromatic water. 
By means of gtich a cutiibmntioii we produce not only 
tti« sj)eciiio iuilitcnw of tlio colcbicum, but at the same 
time kc<!p ujt thi- swin-tbu of tlio bowcU aud kidneyv 
Olid augincut the aUdliuity of tbc fluids. 

While Sellfbort. — Vcnitrum allium, or wliite helle- 
bore, bos boon prepared and used in plucu of colcbicum, 
and a prcpiLrntion of it with opium was at uno timo 
proposed as a substituto for the celebrated Euu &l£di- 
viuiik'. Tho white belloboro is a phint V'louging to 
tho stamo nntiiml order as tho colchicum, tiud the 
rhizome, the part employed in medicine, contains aa 
alkaloid, noined vcnitria, a pi-iuciple which is occa- 
sionally employed as an external remedy. Veratrift 
WHS formerly supposed to be identical with the actiro 
principle of the colchicum autunmalo, and ^cnc« it 
was natural to suppose that hellebore might possess a 
similar action to colchicum. It has however bocn 
recently proved that vcratria and colchicia are not J 
identical, that tbc formi>r U much more irritating than 
the latter, and differs from it in chemical properties. 

Sir C. ScudamorL', who apjmars to liave witnessed 
its effects, thought tliat the white hellebore was too 
dangerous a medicine to he familiarly employed, and 
that it could eetdom be given with prudence to gouty 
patients ; that even in careful and graduated doses it 
often caused serious h}7)Drcatliarsi», grout depression 
of strength, spasms, and cold swt'uts, and in some 
instances, tremors, faintiugs, and tho stnisalions of 



A 



THERAPEITIC ACTIOK OF COLCHICUM. 



3»7 



appriNiehing (loath. I haro tiad some opportunities 
of ascortAiuing th<! vnluo of the white hellebore, aa 
also of tlie alktloid verotriu in the tirntment of goat, 
and tlic folloring com well illiutratva the octjon of tbo 
Utter:— 



^ 



June 18, 1854. A pataeat 60 j«m of igo. who 
had long Kuffrrcd froni gout, Mid hod di^porito of chalk 
nixl much distortion of tlie jointa, was attacked at the 

ovc date «-ith a sevorc fit ; thcr« was swollinj; aud 
lin of both fcvt and right )iaiid, aud many of tho 
smaller jaints of tho left hand and tlie elbows wero 
more or less implicatad- Pubie, 9G ; thirit Ordorod 
to take at d p.m. a draught containing -^ grain of 
Toratria dissolred in aa ounce of water with a few 
dropa of spirit. 

The draught produced some slight naun>a, but do 
other nymptoma; at 10 p.m., y, grain of veratria 
was given, vomiting of a dark-colourod matter took 
place during tho night, and the bowels, previously 
much ounfiDed, wero relierwl. portly perhaps by the 
vertitria, hut he had pre\-ioasly taken on oidinaiy 
senna draught. 

Juiiu 19. Patient feels caner in all joints, bat 
espeoially in left haiid. Pulse 72, not full or hard ; 
thinks be became relieved afUn- the veratria. Ordered 
to take Vv grain of veratria at 4 p.m. 

Juno 20. IIos taken three doses of Tcrafria, no 
feeling of sicknesa, but a cap of (en hag been vomited; 
many of tho joints maob more paiofoL Pulse S4, 



TBEATMBST OF GOUT. 



fuller. To take i grain of Toratrta. three times 
day. 

June 22. After taking tlircc doses of the medioinO) 
felt intense thirst, huming and dryaees of the moutfa, 
but no purging or vomiting ; tUo joints were worse 
than before. Since omitting the medicine, less thirst 
and dryness of the mouth and throat. Bowcla open 
to-day, &om a dose of house medicine. 

The patient was then ordered a colclucuia mixture, 
and aftor having taken it for 2-1 Uourf, tUo joints were 
greatly i-eliovcd. 

Judging from this cnse, it would appear that the 
action of vi'ratria, although carried tu the oxtont <l 
producii^ disagiTcatile thirst and dryness of Hu 
mouth, is attended with no peal alleviution of the 
gouty sjTnptoms ; the slight impruvenient at fiis 
experienced by the patient prububly urosc sok'Iy &xini| 
the rolief of the bowels ; but ,the culchicum subsfr-J 
qucntly udministored, rapidly removed tho articular 
disease, without the production of cither tliirat or 
dryness. 

I have witnessed the administnition of the wine ot 
hellebore, followed by a .similar result; it produced a 
baniing sensation uf the (esopbngus, parched mouth, 
and iuteaso thirst, accouipanied by great dcprvssioii, 
but without any allovintion of the gouty symptoms. 

Tlie difference between the active priiicijiles of col- 
chicum and hellebore is also well exemplified by thft 
foUowing experiments made by MM. Qciger and 




THEKAPECmC ACTIOS OP COLCHICUM. 




nc«»c : — ^ of a grain of coUMcia dissolved in veak 
alcohol was gircn to a oat eight weeks old ; much foam 
almost inunediately appeared at tlio mouth ; at tho 
end of about an hour there were abundant liijuid de- 
jections, followed, after an interval, by romiting. The 
gait of tlio animal became staggering, it fell, rolled 
from Eido to side, uttered a plaintive er}-, and appeared 
agitated by conrulsive movements. Tbeeo sj-mptoms 
gradually augmented, and death took place in 12 hoon. 
On opening the body, the stomach and intestinal cimal 
wero found intensely infiamed and congested through- 
out. A -^ grain only of ttratria, given to a younger 
c«t, caused the animal to stagger more convulsively, 
ud die in 10 minutes; after death, no inflamjnation 
was found, except at the inferior part of tho ccsopltagu:*, 
n portion of the canal not inflamed iu the cat poisoned 
by tho colchicia. In most of tho fatal cases of 
poisoning by culchicum, a similar inflamed condition 
of tho mucous mcmbrauo of tho oUmcDtaiy coDsl has 
been observed. 

I Uiiok we may conclude from these observations, 
that although white hellebore belongs to the same 
natoral order as the colchioum aatumDalo, ita physio- 
logiflal and therapeutic properties are by no means the 
aome, and furthermore tliat it is not a desirable remedy 
in the trutmcnt of gout. 



uo 



TEEATMENT OF OODT. 



CHAPTER XU. 

TtUTxnrr o» Oool: — niroitrAiici of rnwraiat n th* olikono 
ITJ14U or TnK Mii>ftDRR — mkhkihil TMjtTVBtrt or OHHovn 

OUDT — QBKtN.tL 1IE«T(7H OV— VlLCl OV SrWIU Ul 
AI.Ktl.l» ASD MUNIS— DII.IT«ItTS — UTHIX UtM »M)rOmUI U 
CDUTITE AQINT^ — TUEin SPKCIII. UTIUV JXC mVAVTXa: 
UH LEjlVM IR onur— TPBiet — TllKtR VAMtH IH oourT oins — 
rOBTIillD rOVDXR — DISCDSEIOH Df THE UlKlLITr Or TWI<S TO 
VnODITCII IKJDRIOnS OdKIBQUENOSa — TttXlTMEICI Or IIDDT MM- 
rUDtlRU WtTU EtD'Et I'JSEAIN -- THKATUK^T 01 Till LO04& 

ArrcniOFB — oDUi^ — sriFrvEsa of joikts — ohile-rokb— 

OOUTT AmOKBaKI — DIET AXD HEOIXEB IH OltEDKni OUDT. 

WuEX gout, Instond of passing off as an acute fit, 
lurks about the joints, now attacking one, now another, 
with modorat© intcnsityf but with the production of 
mneli stiffening and distortion, it has assumed a font 
to whicli the terra cbronio gout is applird, and on^ 
which requires a treatment cousidoraUy modified from 
that recommeaded for its acute manifestations. If it 
Ic necoasary in acute gout to make the treatment 
dt'iididcnt in a moaaure upon the peculiar state of the ■ 
system or the idiosyncracy of the patient, it Ijecomoa 
a matter of much greater moment to attend to these 
circumstanccB in prescribing for the clironic forma; 
for a treatment, which in one case would be attended 
with essential advantage, in another might prove not 



i 



iHKOTTAKCE OF TRKATMENT OP CnRONlC CODT. 401 



only awless, but positively injurious. In onopationtthe 
development of tho gouty sj-mptoms may bo intimutoly 
usociated with the state of the skin ; in another, 
vith the Gonditioit of tlio Htomach and ita appendages; 
in a large class of eases, a gieatly augmented forms- 
tion of una acid is the chief cause of the malady, 
vhereas in a smaller class the deficient excretion of 
thLi principle may be the most important feature of 
the disorder. All these considerations must be taken 
into account in sitcccisfully prescribing for the disease, 
and although a general outline of the plan of treat- 
ment i» capable of bcin^ delineated, still the deviations 
frgm it must be neoeesarily numerous, and left to tho 
judgment and acumen of the practitioner. 

As we have before had occaaon to remark, the 
use of oolchicum in the early attacks of gout has been 
aoouscd of inducing a chronic condition of the malady, 
bat that fiuch antecedent treatment is not essential for 
its production, I can afRrm from my own experience, 
having recently met with a well inorkcd instance of 
dtronio goat in a patient who had experienced attacks 
for about fifteen years, but had norcr liad recourse to 
tho U80 of any medicines. In this co.^, the fit^ were 
•t first short, and the intervals bctvoen them long, 
but after a timo their fivqiioney was tnerenscd, their 
duration proloogcd, and tho disoaw assumed a chronie 
form, accompoDiod with visible deposits ; provbg that 
there is a natural tendency for gout, gradually to 
ossumo ft more Mvoro and obstinate character, ovca 
when uninfloenoed by roodicuuc 

B * 




iSS TBEATMRNT OF GOUT. 

Al&ough duo attcntjoQ to tlio inSanunntion 
&e joints muat not be lost sight of iu tlie manage 
ment of chrome gout, still the constitutaonal treai 
ment is of paramount importance, and should hav 
reference to the morbid condition of the blood, am 
tlio removal of the impurities with which it is charged 
This object is best effected by increasing the activity 
of the secreting organs, cspociuUy of the kidneys and 
skin ; by altering the composition of the fluids, and 
rendering the abuonnal matter less injurious, but 
above all, by obviating the circumstances which lead 
to the production of tho disease. d 

Witli regard to the direct treatment of the inflani- 
matoiy state of the joints, this can be succeaafuUy 
effected by tho administration of colchioum in veiy 
minute doses, carefully avoiding depression, and attend- 
ing to the precautions before detailed ; but tbero 
arc many cases in which other remedies are required, 
and among these iodide of potajsium and guaiacum 
may be frequently had recourse to with advantage. 
It must be remembered that a tow form of inflamma- 
tiau is often kept up in chronic gout from the presence 
of deposited matter, an action altogether independent 
of true gouty inflammation, and it ia more particularly 
in those cases that the remedies alluded to prove most 
bcDoficiiU. 1 

lodicte of polamium ha» undoubtedly a marked 
power ill u]lo\-iatiiig affections of tho fibrous^ tassues, 
■a u seen in the relief afforded in nodes ; in many 
cases of gout, espeoially when the inflammation as> 



i 




VALUE OF IODIDE OF roTASSllTU. 



4M 



somes the ohartictoi Icnovn \>y tho name rlioumatio, 
the remedy is of great benefit, acting on tbo fibrous 
tiflsaes, and removing the remnants of infismmji- 
tion. In Eub-acutu forms of rbcuin&tism, iodide of 
potassium is pecoliurly indicated when tlie pains an) 
increased by warmtb, and tbv sumo indication may bo 
taken as a guide in chronic gout 

I do not conaidtT that iudido of pota«aum pocaoteca 
any appreciable power iu removing dcpotcitd of urate 
of wxla, but nevcrtltelesK I look upon it as a Talnable 
Vgcat in many cases. Mr. Spencer WoLls itatos that ho 
lias employed tlte iodide witli much advantage when 
jointe hare been eulurgi^d, stiffened, and n.-ndered pain* 
ful by Uic presence of gouty deposits. Tlie do^ of iodide 
of potassium, sufficient fur all Uio good it is capable 
of efiboting, need not be large, &om half a grain to a 
grain may be taken twice or tlireo times a day, in 
water, or in combination with other saline remedies. 

Ouaiaeum is a drug which may also be employed fw 
the sake of ita specifio action on the fllooud tissncs, 
and may be given tn chronic forms of gout when the 
circolatioQ is languid and the pains are rdiorcd by 
the application of warmth. I have found great 
benefit in many such instunocs &om this drug, and it 
is moreover a remLniy which may be administered for n 
long time without pruilucing miaohleroas oonKqucnoca; 
for auj unpleasant (.ffecfat, as nansea or purging, which 
OCOMJonally nnilt, are at onco made manifest both to 
the physician and patient Onaiacum may be giroa 
citlter in the form of the Phormaeopoaa mixture, or 

» »3 




m 



TltEATMEST OF OODT. 



W the nmple or compound tincturo, tlio ammonia 
oontttined in the latter being often beneficial, as it in- 
creases the stimulant action of the guaiacum upon the ' 
vascular system. When inflammatory sj-mptoms are 
present, or when warmth increases the pain, the use 
of guaiat^tim is generally contra- indicated. Ca-ws now 
and then occur in whioh guaiacum may bo combioed i 
with advantage with iodide of potassium. 

I have notes of numerous cases of chronic gout, 
in which guaiacum hiis been employed uHth striking 
benefit : it will be sufBcicut to select one for the purpose 
of illustration. 

1860. — A gentleman, fifty-six years of age, without 
any known predisposition to gout, experienced the 
first attack about twenty years since, in the ball of the 
great toe ; there was at least seven years' interval 
between the first and second fit, and three between 
the second and third. After this time the intervals 
were diminished. During the last three years the 
attncks have been much more frequent, and especially 
within the preceding sis months ; the fits have 
heen also more prolonged, and the upper extre> 
mities have been nifoctcd as well as the lower. 
A small spot of urate of (mda can he seen in the 
helix of the right ear, and there is gome stifiuess 
of one or two of the phalangeal joints of the fingers. 
The urino is free from albumen, and clear, yieldbg 
but 8 small amount of uric acid wbeu acidulated. 
The pulse is weak, 84, there is no indigestion, and 
perqiiratioD is easily ioducod ; be has noticed that all 



VALUE OF GrAUCUM. 



MS 



slicM^ to the system, mental a.<i well as ptij'sical, ore 
liable to bring on an attack of gout, and the fits liaro 
been more frequent in summer than winter, Guaift- 
cum was ordered for this patient, in the form of tho 
ammoninted tincture, rubbed up wiUi macitage, and 
he vas also advL^od to take, occasionally, a groin of 
tlic acetic extmot «f Gotcliicum, combine<l uritli n little 
quinino. Under tho influenoo of this trcatmont, the 
progKSH of the disease bccamo arrested, and now for 
nearly two years lio bus bccn but elijjhtly truubtcd 
with gouty symptoms. 

I have known niiiny ether cases in which tho good 
effects of guaiacum have been equally marked. 

Other stimulant lemcdies, as mfzercott and ierjten/arjf, 
maybe given to fulfil tlie same indications as guaiacum, 
either in the simple form, or as the compound deooc- 
tton of sarsaparilla, which unites tho virtues of tkeso 
drags as well as tliat of the sarsaparilla itself, and is 
a convenient method of exhibiting them. Sulfihtir 
liiui likewise been occasionnlly prvfcribed with tho 
itamc view, and is now and then useful in chronic 
fomu of goat. 






To romoTO tho abnormal state of the blood whicli 
invariably exists in chronic gout, and to restore the 
ctrcalating fluid to u state of purity, must be our next 
object It will bo ivmcmbored that tlio presence of 
umte of soda in tlio blood bus bocn ahoim to depend 
on two catuos; lir<t, ita unduo (ormationt ariaii^ 
from nmo form of dyspepsia or inal*a9similsttoo, 



■*« TREATMENT OF GOtlT. 

eocondly, iis deRcicnt excrctiuii from the renal orgaiu. 
Th&sc causes arc often found combined, but in Romc 
gouty Rubjoct's Uie first is most prominent, in others, 
tbo second, consequently our treatment must be modi- ' 
fiod to suit the different cnscs. Tbo undue formation 
of uric ncid will be found to bo espceiiiUy influenced 
by diet and regimen, wbercos its dcticient cxcrotioii 
is more under Uio control of remediol ngcntj ; upon 
tbc lattt^r we aball first discourse, but previously to 
so doing, I cannot help alluding to Sydenham's udnce ' 
with regard to the tieatnieut of gout, in which ho 
remarks, tliat remedies, to be of service, must be 
iiiy mid perseveriugly adhered to ; that a change 
le whole s>'st<'m is required which no seneiblc man 
can believe is possible tu be effected iu n short time : 
he then goes on to say, " For years together a man 
has drunk nnd feasted — has omitted his usual i-xcroiso 
— has groira slow and sluggish — bos been over ' 
studious or over anxioos, — in short, has gone wrong ■ 
in some important point of life. In this case ho has, 
as it were, taken trouble (o pervert the various fer- 
ments of tlie body, aud to smother the animal spirits, 
which ere the primary instruments of concoction. 
JTcnce the humours pretemntu rally accumulated, 
break forth, after having become exalted in the 
highest degree. They destroy the system. The 
muscle-* are softened and the joints relaxed, so that 
the affluent humours arc readily received. A aer 
nature is now superinduced, the original and natural 
economy of the body being altogether broken up 




TALUK OF AUKAUn, 



tn 



•ai ibrtToyod. TLo fito tbut seem so imporfaat in 
Om ayes of tho party, arc nothing more than the 
aerios tnd order of symptoms which natoro uses in 
tho cxpol^oD of morbific matters. Hence, to utc 
any medicines for a timo is a waste of labour. Tho 
wrakness of all the digestions, and the lo^t of natural 
strength in the scverttl parti<, are the ettsoitco of gout. 
Each must bo dealt with." 

Th« Tcmodti>s boat ndnpted to parify tho blood are 
those wliioh incrcaso tho activity of the secreting 
organs mora cspocially the kidneyti, as also soeli as 
poMon (he power of rendering the preaenee o( tin 
onto of soda li»s iiijuriou.i by prerenting its fnrtlier 
deposition io tho tiMucs or removing it when already 
infiltrated. To cfft-ct these purposes olkiilics ond 
salinee are peculiarly called for, and many of them are 
of sufficient importance to demand a special inquiry 
into their nature and mode of action. 



APtaiie* and Salinn. — Alkalies and salinea hsTO 
long enjo)'cd reputation in the treatment of ohronia 
gout ; Boerlioavo and Hoffmann reoommendcd them 
to be taken in small and frequently repeated doses for 
a long while, and for this purpose employed the uhos 
of different plants, burnt either to blackness or wlul«> 
warn; Ua example, broom ashes dissolred either in 
water or Rbenish mne : they also used the alkaline 
earths for tho nuno parpoM. Cullea remark* tlut, 
when some fixed alkali, either in a mild or caostk 
state, or lime-water, soap or absorbent earths, hare 



«s 



TSKATMEHT OF COUT. 



been given in Dcphritic or calculous cases to pati 
who were at tho sanio timo subject to gout, it has 
observed that, uihIlt the use of these mvdicoiics, thofi 
have been longer &ee from the fits of the kttcr di 
Ho adds, that he docs not know, if whon very lo: 
continued, they woidd prevent the returns of gout, 
lie had never ventured to giro tliem for so long 
period, fearful of prodacing a hurtful change in tho 
blood. Dr. WoUaston, in alluding to his discovery of 
the real nutuio of gouty chalk-stones, and in referring 
to the opinion just quoted, saj-s, " The knowledge of 
this comi>ound may lead to further trial of tho nlka- 
liea, which havo been observed by Dr. Cullen to be 
apparently efEcaoiouei in preventing Uio returns of tbia 
diseoAO ; and may induce us, when eon-ecting tho 
acidity to which goutj- persona are frequently subject, 
to employ the fixed alkalies, which are either nf them 
capable of dissohHug gouty matter, in preference to 
the earths, which can have no such beneficial effect." 

Magnesia and lime have, nevertheless, been recom- 
mended in gout, and cases are on i-ocord in which the 
attacks appear to have been kept off for some time by 
stctuly pei>;cvorancu in their exhibition. 

Some pb>'aiciane, on the other band, have had no 
confidence in tho administration of alkalies ; but it will 
be found, that tho ojiponents as well as the partisans 
for these remedies, have been considerably biassed by 
their respective ideas of tho natui-e of the disorder ; 
upon the whole, tho recorded facts ore in favour of 
benefit having been derived Irom their use. 



i 



VALUE OF ALKAUEa 



In my romaikfl on tho value of alkalino rcni<^0<, 
I shall iDcludo not only tho alkalies and their oor- 
bonatoji, but also such ncutreLl salts us tho citrates and 
tartrates, which utc decomposed in the blood, nnd 
rcndor tlio urine k-ss oc-id ; in addition to tbcM I 
shall speak of certain tmlinc subManocs, as tbo phoe* 
phato of sodft nnd phuNiiiiiito uf nminoniu, which exert 
a specific aclioo upon tlio renal and cutaneous secre- 
tions ; but before entering at length into the value of 
these remedic*, it will be advisable to say a few words 
in Tcfcrcnoo to tho diScrcnco of action wluch ihej 
respectively oxort 

It must bo remembered that when caustic potadi 
is administered in tho fonn of liquor potossic, tbo 
amount of tbi; alkali capable of being introduced into 
the GyHtent is exce):<ditigly ininutc, and it8 iufluonco 
is probably exerted chiefly upon the mnoous mcmbraoa 
of the stomach and ita contests, and it therefore 
acts simi^y as a direct antacid and local acdatiro, 
the alkali absorbed being iiunifSoient to nmdor tho 
urine cither neutral or alkaline. But when tbo oar* 
bunatcs nnd bicarbonates of tho alkalies are given, 
eo much of tho salts may be introduced into the 
etomaoh as not only to noutraliac the acidity of tho 
alimentar}' canal, but to render the blood more alka- 
line, and notably alter tlio seeretiou of tho kidneys, 
and this is moro especially obecr%'ed after Largo dosM 
of the bicarbonate*. 

The same pbenonuioon is obaervod when the com- 
meit phoflptiutc of eoda is emplo}*cd; a salt which 



410 



TREATMENT OF GOUT. 




possesses un nlkoliiio reaction and pasaes tlirough the 
sj-stom apparently iinchnngttj. 

In the ca.*e of the citrate and tartmtcs tho effect is 
different. These salts nre neutral, and do not therefore 
possess the pciwor of noutrnHMiig acid in the stomach, 
hut, after their absnrj)tion into the blood, they are 
decomposed by tho oxidation of the regctable aeid% 
and afterwards thrown out by tho kidneys to tiie 
form of tho carbonates of thi'ir i-cKpective alkalies. 

As yet wc haTC spoken <if nil tho alltaliiio salts as 
cxcrtiog tho some influence, but this is only con«ct 
up to a certain point, beyond which a difference of 
effect is dlstini^ishable. Looked upon physiologically, 
potash salts act more especially upon the kidnej-s, and 
induce powerful diurest.s; soda salts influence tho 
liver moro than potash salt^, but act less apon the 
kidneys; and in a chcmico-physiological point of ricw, 
the uric acid of the blood and urine is rendered much 
more soluble by the potash salts than by tho cono- 
sponding salts of soda. 

The influence of tho potash salts as diuretics is well 
shown in some cxpprimcnts of Professor C. O. Mits- 
cherlich of Berlin, recorded in his Lehrbuch der 
Araieimittelli'hro. This physician gave half drachm 
doses of carbonate of potoith dii^olred in six ounces of 
water, to a man suffering from prolapsus veaicm. In 
half an hour the urine became ucutral, and in 38 
minutes alkaline. The quantities of urine which wore 
secreted in each 20 minutes were as follow, measured 
in cubic ccntimctcre : — 



i 




AfUr iha lint 20 iDiuntM32 euli« OMt.— «p. [r. lOSO 

Aflvr th« oKuoil 20 „ 49 „ „ lOU 

Aft«r the third SO „ 79 „ ,, 1009 

After the fouftli 20 „ BO „ „ lOU 

After tbe itth SO „ SO „ ,. 1018 

!nie total quimtity in one hour and 40 minutes being 
S36 cubic centimeters, or a littlo niun- than oight 
ounces. The same patient, whiia not under tho influ- 
ence of the drug, passed, un lui overage, le^ tliua two 
OQiiccs ia the same ported of liino. 

In soother experiment the Humi> man look IQ ounces 
of pure water, und the urine passed in exhibited in the 
following table : — 

After (be Gnl 30 minuUi 31 caliio Mnt.— «p. p; 1090 

After tbe KoaDd SO „ 33 „ „ lOlS 

After lb< tlilrU 20 „ A 1 „ „ 1000 

After the feorth 20 „ H „ „ lOOl-S 



I 



Thus showing that pure water, although it augments 
tho secretion of the urine, U much lc«s aotive as a 
diuretic than a far less qooatity of a eolutioa of 
biootionato of potash. 

Ho obecrv-ntions of the action of soda salts upon the 
kidneys in comparison with the corresponding salts of 
potash are on record, although the &ct of this diflerence 
in diuretic action is, I believCi generally adntittod. 

Potash and w>da Kidts differ al^i vcrj' notably in 
their inflofinoe on the blood, and more especially in 
their power of imparting solubility to uric acid. This 
might be at once inferred from tho greater solubili^ 
of urate of potufa, and may likeviso be obserred in 



^l3 



TRRATMENT OP OODT. 



wfttching tto effects of tho two remedies in clearing 
the urine of patients from deposita of urates. The 
same fact may bo illustrated espcrimentally j if, for 
example, small portions of gouty cartilage, iuiUtratod 
with urate of soda, bo placed in solutions of (ho 
carbonates of the t«'o alkalies, it will bo found 
that, after the portion treated by the potash has 
beoome quito free from the urate, that immersed in 
tlie soda solution remains apparently in its original 
state. 

Having established the inHuenco of these salts in 
rendering the fluids of the body more alkaline, and 
ill causing the solution of the uric acid, it is novr a 
matter of importance to ascertain if the results of 
clinical experience accord with these facts. I should 
bo inclined to lay great stress on Cullen's statement 
with regard to the therapeutic value of alkalies in tho 
treatment of gout, because ho was utifuvourablc to tho 
idea of the disease being iii any way connected with 
impurity of tho blood, and he makes the statement 
merely as a result derived from actual experience of 
cases in which the alkalies were prescribed for a 
different purpose. 

That alkalies are useful in treating acule attacks of 
gout is a fact recognised by almw.'it every physician, 
and the oxLibitiun of these remedies in such cases is 
very common ; but it is a question of far more import- | 
eincc to determine whetlier, if their use be Jong pcrec- , 
vcrcd in, they exert a beneficial influenco over tho 
future progress of the disease. It may ho well that 



TAU'E OP AI.KAUF& 



ta 



I 



should give the result of my own experience upon this 
point. 

First, T am of opinion that nlkalino romodics ve of 
much value in the troatmi.'nt of the p&roxysnu or 
exacerbation a of the joint affection, and I (un con- 
stantly in the bahit of prescribing tliem in ^ch cases, 
either in tho form of the bicarbonate of potash, or of 
the citrate or acetate of the Hunc base. I prefer tlio 
potash to the soda salts, because the former possess 
tho sftino alkaline propcrtice as the latter, and hare 
• greater S(^vcnt power for uric acid, in addition 
to which the production of diurosis is attended with 
advantage. 

Iq some instances in which magnesia is indicated, I 
bare replaced tho potash by this base, but for a short 
time only. 

Next with regard to the continuance of the remedies 
when no inflammatory joint affection is preecnt, I 
am con^-inced that mucli benefit may bo derived from 
a judicious admini«iration of mlines continued for 
a long period, and can bring forward erideneo in 
sapport of my conviction ; but to render them suo- 
eessful in sucit caacs a particular form of cxhibitioD 
shotUd be adopted. 

If a patient sulFeriiig from chronic goat is exempt 
from active tRflainmntor}' symptoms, the following 
Tulos should be atleuded to : 

Tho ealined should be given in small doses, and 
npMlod two or three timi» a day. 

Thof diould be administered in a ury dilitto finrn* 




414 TREATMENT OP COl'T. 

and always on (in empty or nearly empty stomacb, and 
somo little wliilo before food. 

Tho nature of the ealiue most depend on tfao 
poculiariticfl of tho caso, and it eboiild be changed 
from time to timu. 

Small du^cs arc for nittny reasons preferable to 
large, when tho continued omployment of such 
rcmodios is desirable, as thoy produce no disturbance 
of tho digestive organs, net more fieely on the secre- 
tiona, and are not likely to induce the debilit)', which 
is occasionally seen if thoy ore given in considerable 
doses. 

It is of much importance that the salines should be 
dissolved in a large quuntity of liquid, and for this 
purpose I usually proscribe cither plain or aerated 
water. Tho water itself is doubtless a powerful agent, 
and, if judiciously employed, of much service as a 
remedy ; it is one perhaps too much neglected by 
physicians of the present day. 

If water bo given when tho stomach is cmpt;^, 
it is rapidly absorbed by tho veins, imd quickl}- 
^iminated by the difTerctit seuretiiig orgiiii*, who6e 
functions are thereby greatly excited, and then, along 
with tho augmcatcd watery secretion, matters which 
would otherwise bo retained, arc thrown out, and the 
blood thereby rendered pure. I have reason to be- 
lieve that the increased exoretion from any organ is 
always nttetidod with an ougmentation not only of the 
watery portion, but litowi.se of the solid matter of 
such excretion ; that when, for example, diuresis is 



J 



VALUE OF THE FBEE DILCTIOS OF SAUSES. tlS 



I 



induced bjr any means, more of the peculiar ingre- 
dients of this fluid aro at tlia same time cUnunatod, 
»iid that no Kucb diffcniuco exists Ictwcvn diuretio as 
Lu been occasionally asserted, uuniely that one cla«s 
mvn>ly augmeuts tlio watery portJuu of the urine, 
whereas the other iucrvaxcs the urgunic and inorganio 
solidjt. Wo havo evidence of the Ttduo of water as an 
notivo mcdieinikl a^ut in thu fact that mineral waters, 
holding in solution var)-ing uinounta of saline matters 
and salts of ver)' different oomi»Mition and cbametcnt, 
act equally efficaciously in relieving the samv disease ; 
a circumstance probably depending in a great measure 
on the powerful influence of the water itself. As 
the result of numeroos observations I am of opinion 
that the Irco odministratioa of water nt proper periods 
of iho day, diminishes the formatiuu of uric acid 
in tho system, at tlio samo time that it promotes its 
elimination by the kidneys. When, for examt>Ic, tlio 
urine of any [lutieiit is increased in quantity from this 
cause, the uric acid becunes notably lessened, oer- 
tainly to a degree incapable of being explained by the 
£act of tho solubility of the acid in the fluid, and tho 
greater difficulty of separating it iu the anulj^sis. Thi» 
new accords with the obsorvatious of Ikmker and 
Qenth, who found a marked decroaso of nrio acid 
under the same oiroamstunct.4. 

Tho reason why dilutv saline rolotions ore moro 
effieaciout when token on an empty stomacJi arises 
from thcar liability to produce dyspepsia if otherwise 
administered ; wator itwlf will cause indigestion if 



m 



TRE-ITMEKT OF GOUT. 




taken soon after a meal, and the disturbance of the 
stomach will be further iiicruiLScd if un nikali bo dis- 
fiolvcd in it. 

The choice of the saline is a point of some impor 
anoe. I am inclined to regard almost all saliiips as' 
beneficial, but some arc certainly more adapted to 
particular cases than others. When the function of 
the sJtin is imperfectly performed, the salts of ammoDia 
are peculiarly indicated, and the phosphate may be 
employed with advantage ; it possesses also consider- 
able solvent power for urate of soda, and there is 
much clinical evidence to proro its value in the treat* 
meat of chronic gout. It wiis first introduced as a 
remedy for tliis disorder by Dr. Buckler, nf Baltimore, 
and since that period has boon employed by sovcrol 
physicians with success. "Within the last few ycais I 
have used the phosphate of ammonia very extensiToly, 
and tan well satisfied Avit)i tbo results obtained from 
its cmploj-mont in chronic gout. 

If there be a deficient secretion from the kidneys, 
the salts of jiotash are desirable, on account of thdr 
diuretic properties ; added to which they pc^sesSi 
OS before stated, great solvent ])owcr3 for urate of 
soda, and I am fully convinced that tliis latter pro- 
pert>' plays a most important part in the therapeutic 
action of the drug. 

The phosphates uf potash are not much employed, 
for the salt which corresponds to the common phos- 
phate of soda is not one which is pharmaccuticuUy 
convenient to administer. 



i 



VALUE OF*8AUyE8. 



*\7 



The cdtrato of potash U oho T&laable and prixluccs 
no distorbaocc of ike etomach ; it 13 agreeable to tlio 
taste, useful when a direct antacid is not Tx^quired, aod 
may be advaQtageotuly given in the cfferrcAoing form. 
I'he acetate is less pleasant, but is on efBcacious salt. 
The tartrate in the majority of cases is not desirable, 
from its liability to raa off by the bowels. 

The chloride of potassium may bo occasionally pre- 
scribed as a diuretic and solvent ; it ia a normal 
constituent of the blood, ultbough in a much smaller 
proportion thou chloride of sodium. 

Having frequently pru«cril)od .tulinc n-ncdin in the 
mntuiCT above described, I con spook most favonrubly 
of th«ir value in chronic gout I have repeatedly 
given them to patients who hod for many years 
suiFored annually from numerous sorere attacks of the 
malady, nvith tlio oflect of keeping them free from ita 
rctom for a whole twelvemonth, imd this excmptjon 
hM bMO aoconiponied with a di-cided inii>rovi'ment in 
(he gooend health. Uiwu the whole, I liavo found no 
other treatment so efficacious in ciocs of unoomptioatod 
chronic gout, and it is one attended with this great 
advantage, that it can scaroely t>e regarded in the 
light of drugging, as no foroigu body is introduced 
into tbe economy, bat merely a slight additioa made 
to the salino matters which are present in many 
orticlos of food, which are normal to the constitation 
of the blood, and crca oecessory to its heahhy cooati* 
tution. 

Jbi the case of a gentleman 50 years of age, rafferiag 



* ■ 



<18 



THEATMEKT OF'CHKOHIC GOUT. 



team ebronic gout mid mucli cn^iplod with chalk- 
stones, tliis trofttmont was followed witli sucli good 
reflolts tliat ho wfis Me again to CTJoy field sports, 
from which he had been long debarred; and this im- 
proTcment was in no way favoured hy any very rigid 
adhesion to diet or regimen, 

For Buch treatment to prove succossfiU, it is import- 
ant that it should not bo indiscriminately used, and 
the fuses should he properly selected : it is inappro- 
printc for persons who are either greatly advanced in 
years, or whose kidneys are so injured and contracted 
that their power of eliminriting the watery portion of 
the urine is much impaired ; and lastly, it cannot be 
advantageously employed when the patient's stomach 
is unable to bear ^ritbout discomfort dilute saline 
solutions ; for if a feeling of distension and weight, or 
other symptoms of dyspepsia, is induced, the treat- 
ment will probably do more harm than good. It 
sometimes happens that when the simple saline solu- 
tion does not ait ooitiiy on the stomach, it may bo 
made to do so by the addition of some antmatic bitter, 
and a weak infusion of ohamomile or of asb-leavcs 
may be substituted for the water. 

Tlie salts of magnesia and lime may be occaaionally 
Tued instead of the alkalies ; their ordinary cmploy- 
ttcot, in lieu of the alkaline 8alt^ offers so special 
adrnntnge, but on the other hand may be attendi-d 
with discomfort ; the first being liable to run off by 
the bowels, tho latter to cause constipation.. In> 
sttmccj, however, occur in which the administration of 



urniA SALTS IK corr. 



41 B 



I 



I 

I 



De or otbcr niny for a wliilo prove somccaUc ; in 

cli the solutiun of tlio bi-carbooato of magnesia, or 
limo-wfttcr, may bo had recourse to. 

Lithia Sa/fa in Ihe TreatmetU of Qwl. — Litlus 
was Rnt discoTcnnl by ArfiradsoD in 1817, in 
tlic mineral Ptlalit^, and was so namod from 
kWuoi, stoue-likt. It has boon since cxtnolcd from 
several other oiincnilK, and boa been fitund in many 
medicinal eprings, at those of Carlsbad, Aiz-Ui-Cha- 
pello, Maricnbad, Kisseogon, Ems, Teptitz, Dilin, 
Krt'UicuaGh, Vichy, Baden, &e. 

The metal litliium, of which lithia is the oxide, u 
of a beautiful white colour, like silver, readily oxidised 
by exposure to tlic air, of a tipeoilio g:ra\'ity about half 
that of water, in faet lighter than any known liquid. 
It ia also remarkable from possnang a very low 
oombining proportioD, its equivalent not excei-ding 
seven on tho hydrogen scale. 

Lithia forma tho third fixed nlkalt, and occurs a> 
white crystalline substance, hanng a caustic taste, and 
an uitcDse alkaline rc-oction, nmilar to potash and soda. 
In some of its characters, lithia closidy approadica 
these alkaline bases, in otiiors it more rrsemllc« 
auigmgia and lime. Tho proto-carbunate differs from 
the alkaline carbonates in being sporin^y soluble in 
water, requiring about lOO parts; with excess of car^ 
bonic acid it Ls rendered more soluble. Lithia, when 
dissolved in 1000 parts of wattr, yields a solution 
baring a well marked alkaline reaction. 

As the et^uivnlent of lithium is small, both the alkali 

a ■ 3 



4» 



TREATJIE.NT OF CBROSIC GOUT. 



and lis oorbonntc posi«vitsgi'cat ueutrsluing powct^ Ar 
exceeding iti tWis Ti.«|H.-et the currespondiDg prcpam- 
tioQs of tlic otLcr nikaliuo buses. 

One of the most remarkable properties of lithiu ts 
it« power of impiirting Wuliility to uno aoid, tlio urate 
of litliia being tlic most soluble of tlio known urates. 
It Iiaa been found by Lipowitx, tbat when the mineral 
Iqiidolito is ri'ducvd to powder ond boiled with uiic 
aotd, so great is the uffiuity of the acid for this boso, 
tiut urate of lithift is fmiucd, altbougb the alkali woe 
previously combined witli silioie acid. 

I have found dat when carbonate of litbin in 
excess is boiled witli watert the addition of urio add 
cnusos it to dissolve, showing tluit the urnto of the 
buo is more soluble than the carbonute. The (alt 
formed under these circumstimces irt tbc bi-uratc of 
litliia, which cryatalli.st's in long nccdlos, und eorru- 
sponds to the salt of soda found iu tho blood and 
tiasucs of gouty subjects. 

Urate of litliia is much more soluble in water Hum 
any other urate, but to what extent has not botta 
accurately determined. Lipowitz, however, found that 
one part of carbonate of litbia iu ninety parts of water 
dissolved, at a boiling tt-mpcrature, four parts of niic 
acid, with tbc evolution of caibonic acid, and tbat tlio 
salt so formed, when &ee from oarbonatt^, dissolved in 
nxty parts of water. 

Mr. A. Ure ascertained that a solution of one gram 
of carbonate of litbia in an ounce of di&tillcd irator^ 
when raised to the tt-mperature of 90° Falir., and uric 



i 




UTHIA SALTS IN OOCT. 



«1 



acid gradually nddcd in minute i>orti<vn» until it oeascd 
to disxolro more, took up 2'3 gnuns, a quuntitj' nucli 
Uiger tEaQ tlint dinsolrod l>y either corbonato of soda 
or carbonate nf potasb. Binswanii^r also found that 
one part of carbonate of Uthia in 130 i>arta of water, 
dissolrcd at a blond heat iiearlj' four parta of uric acid. 

To show the power which carbonate of lithia pos- 
eeaea in rendering urate of soda soluble, I made the 
following experiment : — A metacarpal bono wea se- 
lected, bax-ing the phalangeal extirmity completely 
inBltratod with gouty deposit ; this was placed in n 
ematl quantity of cold niiter, and a few grains of car- 
bonate of lithia added ; in the course of two or three 
days, when the head of tho bone was examined, no 
deposit could be «c«n, and the cartilogv appeared to 
hare been restored to its normal stoto. 

^10 litliift nits can erarculy bo said to have b«eD 
employed therapeutically until recently introduc<^ by 
m>'«clf in tbo treittmcntof uric ncidgrarol, and elironic 
gouty conditions of tho habit Mr. A. Urc had pro* 
posed the use of tlio carbonate as an injection into the 
bladder, for tho purpose of dissolving calculi, and iu 
a paper publishod in the " Pliarmac^aticiJ Journal," 
August, 1843, giycs an aooount of an experiment in 
which he found that a urinary calculus, compated of 
altoniatc luyors of nric acid and oxalate of lime, when 
placed in a sohition of four grains of carbonate of lithia 
in an ounce of di.'ttilled water, and steadily mnintained 
at ■ blood hcnt during fire consecutive hours, lost fire 
gmios in wetglit. Tlio difficulty of procuring tho salt 



*i» 



TREATMENT OF CHEONIC GOl'T. 




prevented Mr. TJto. from pursuing liis iDquiries iq 
its action as a scjlvcnt fur vesical calculi. 

About four years siucc I cummt-nced the odminis- 
tration of carbouate of lithia as an iatcmol remcdyi4 
botli in case!) of urio acid diathesis oonnccted with* 
gravel, and Ukovisi} iu chronic gout, and, from what I 
then experioncrd, was much satisticd with tho reeults. 
"Whea given internally in doses of from one to flro 
grains dissolved in water, and repeated two or tbrco 
times a day, it produces no direct physiological aymp* 
torn, hut, when patients* are voiding uric acid gravel, it 
exerts e. marked inHucnoe, causing the deposits eitlicr<1 
to become less or to ceaso altogether. In many in- 
stances in which I administered it to gouty t-uhjccts, 
tho result was to diminish the frequency of the attacks, 
and to improve tho general condition of the patients. 
These obsejTationa led me to propose, in the first , 
edition of the present work, the salts of lithia ss ' 
valuable i-emcdial agents, and, although I was assured 
by tlioso most competent to give an opinion on tho j 
subject, tliat it would ht- almost impossible to procuro i 
a single pound of tho carbonate of lithia in Kurope, 
I believe I am not in error in stating tliut notwith- 
standing its high price, more tlian a hundred pounds 
have already been therapeutically emjiloyed in this 
country. The value of lithia salts iu the trc-atment of 
gout and gravel is based, first, upon the great wn~i 
tralizing power of tho alkali, arising from tho low 
equivalent of this metal, and secondly, upon its power- , 
fill aolvent action upon uric ucid ; in addition 



I.1TH1A SALTS IN COLT. 



ta 






which its local ioSucnoo ia slight, snd its use don 
not appcKr to be attended with any injurious con- 
sequences. 

To dcmonstrnto tho superior power possessed by 
cwbonato of lithia orer tho carbonates of soda or 
jiotosh, in removing tlio deposits of urate of soda from 
gouty caitilogo, I porfonued the following experiment. 
SolutioDS of tho salts of lithia, potash, and 5o<la, were 
prepared witli ono grain of each of tho dried sails 
to the fluid ounce of distilled water ; into these wero 
placed small pieces of cartilogo completely infiltrated 
witli urate of soda, which were allowed to remain for 
fort)--eigbt hoars. At the cod of that time, iho cutti- 
lage taken from the Uthiu solution was found to haro 
been restored to its natural condition, that from tho 
potosli was much acted ujion, but that which had been 
submitted to the influence of tho carbonate of sod« 
appeared nn altered. 

If the experiments be made with other salts of these 
bases, u tho sulphates or chlorides, tho powerful 
influciiGO of lithia will be at onco apparent : when, for 
axanplo, tho sulphate of Itthin cnmes in c<mtact with 
til* matt of soda, decomposition ensues, sulphate of 
Mda and urate of lithia arc formed, and any depositin 
tho eartilago is thus rendered folublc. 

In administering the salts uf lithia, we should bo 
guided by lbt< following coosidentious: 

They should ho given iu a freely diluted state, either 
diswlvod in a largo qnoutity of plain wattr, ur, which is 
prcfinvblc, in a^ntcd wator, fonning JilJiia-trater, and 



^ 



421 



TKEATMENT OV CHRONIC CODT. 




ooiresponding, excq>t in sircngth, with tlie soda and 
potash- waters in geneml uso. 

Whca a large umouiit of on olkali is dc^aUe, I 
have usually proscritjcd the carbonate of lithia in 
coDibinatiuu vrith some salt of potash, as the carbonate 
or citrate, \t-hidi may be adruDtageoualy administend 
in tbc nvmtcd state. 

Carbonate of lithia eau also he given with pboiplucto 
of ammonia ; but it niiut be rcmomb«HHl tliut the pliOB- 
phatc- of litbiu is very sparingly soluble in water, and 
therefore in pro^ribing a eombination of tiicnc salt*, free 
dSution with plain or aerated water must bo empoylcd. 

The great bar to tlie ireo uso of suits of lithia in 
mL'dicine has been their expense, but in tho smnll doses 
in which they arc usually required, this is seldom a 
serious objection. It is prubabla that should tho om- 
plojinent of Utliia in medieiuc bo increa^iHl to tho 
extent which may be reasonably anticipated, tlie 
supply of tJic drug tfill be greatly augmented, and its 
cost proiiorlioiially diminished. 

^Vithin the last two yean the salts of lithia have 
acquired on additional interest, not only to the 
chemist, but also to the therapeutist. This intercct 
has been excited by tlic extensive use which bus been 
made of them in medicine, iind by the recent dis- 
coveries of Kircboff and Bunsen. I will give a short 
outline of these latter, as far as concerns tho scientific 
physician, and relate the results of my own cs- 
porioncc since I first proposed the salts of lithia as 
therapeutic agents. 



tlTHIA SALTS IN OOCT. 



49S 



By the old methods of analysis it was a matter of 
eoandenblo diiBoiJty to detect tlie presence of sniaU 
smonnts of UtLia, but DonseD, by means of the spectrum 
analysis, has shown that the deioctioQ of cycii the most 
minute traces of tho metal can he easily accomplished, as 
lithium givee a welt marked and characteristic red line, 
d polo yellow band, and a peculiar Uuc line at eleratcd 
tempera tores. It has been shown that lithia, instead 
of bviiig, DS ite Domc implies, n dtiistitucnt of minexids 
only, is extenarcly diffusi-d tlmjughout the regetaUe 
and animal kingdom^ and it hu already been do- 
j^cctod iu thu water of the occaa, in many mioen] 

rings not mentioned above, in the ashes of sea-wix'd, 
and of many tidnnd plants, as tho vine, tobacco, and 
in the Bc«ds of tho grnminMc ; oIm in tlie milk, blood, 
and tho uiuclc« of tho liuinau tubjcct, nitd of mouy 
auinals. 

Lithia must therefore nov bo regarded, not u t 
drug foreign to tlio economy, but as a normal con- 
stitaeut of the body, and essential to its woll-bciog. 

Tho quantities of lithia existing in the above-named 
substimccs is small, but it is asserted that in some of 
the Budcn-Badcu springs, the Fettquelle snd Mur- 
quelle, the amount is such as to render these waters 
not only powerful therapeutic agents, but useful as 
sources from which to procure the lithia salts. 

My own experience of the action and uses of lithia 
may be thus summed up. 

Tho QtrboRaUi of lithiu ap{wurs to be a powerful 
diuretic^ in some paticitls increasing the flow of orino 



4« 



TREATMENT OF CHBOSIC GOUT. 



to a somowlint aouoyiiig extent ; nnd I bare known 
many iii-*tan CCS iiiwliiiji a bottle of litUia-watcr, taken 
at bed-time, would cause the patient to be disturbed 
during the night, wbcrcoa the same quantity of soda- 
water would produce no sucli result. 

The carbonate of Uthia is likewise a very powcrfiil 
alkalizing s^nt. In some patients I have seen the 
urine become distinctly alkaline from the exhibitiou 
of fivo grains of the carbonate dissolved in aerated j 
water, and in numerous cases I have known the 
administration of the same salts prevent the de- 
position of uric acid gravel for an indefinite period 
of time. 

I liavc also ascertained, from considerable exp&*. 
Hence, tliat the proper administration of lithin has 
coufiidcrable power in preventing the recurreaoo 
gouty paroxysm*, and have heard of patients who 
asserted that when taking tlio alkali they could even 
indulge in wino with impunity. I have also bcon 
informed that indi\'iduab have lost gouty concretions 
by tlie long-contiimod use of the salts of lithia. 

If wo consider the pathology of the gouty paroxysm, ' 
and remember that in every case a deposition of a 
crj-stollino Eubstance takes place in the tissues of the 
part affected, and if wo then call to mind the great 
power of lithia, not only in alkalizing the blood, but 
likewise in rendering the uric acid soluble in that 
fluid, we shall have no diiEculty ia belic%-ing that theJ 
aalta of this alkali may prove most powerful in (hoj 
treatment of gout, and Ukcwiso in other uSect 




UTIIIA SALTS IS COUT. 



m 



I 



the psUiotogy of which is olosoly oounected vitL on 
excess vf uric acici in tLc syrtcm. 

The citruto of litliia has been lately employed in 
medioino, and is a valuable- salt wliou llio presence of 
a free alkali lq tlie sloniocli ib not ileiiired. It is a 
TCT^' definite cry»tallino substance, readily soluble in 
water, and devoid of any disagreeable taste. It 
exerto no alkaline ]}ower upoo the Gtomach, but when 
absorbed into the blood is readily decomposed, and 
appears in the urino as a carbonate of the base, and 
thus produces all the remote effects of the last named 
salt. It stands, in fact, in the same therapeutic rela- 
tion to the carbonate, aa the conespooding salts of 
potozh. 

I may mention that although many of my patients 
Lore continued the use of lithia salts fur a long time, 
I have never been able to detect any injurious effects. 
I hare beard of the case of a gonUcman who thought 
it produced some ncrrous symptoms, but thia was not 
well made out: the patient notwithstanding cod- 
tinoed the modicine, as it gave relief to liis gouty 
sj-mptomA. 

I wish it particularly to ho understood, that I 
do not consider lithia will in any way replace 
Golchicum us a remedy for gouty inflammation; it 
may prove a valuable adjunct, but its chief use is 
to chronic goaty cases, to word off attacks and 
remove th« remnants of tho disease ; it is likewise 
valuable when administered as part of the prepliyluctio 
treatment 



4U 



TRE.\TMEirT OF CIIROKIC GOUT. 



Finnlly, litliin snits are of Uttlo or no avail in 
rheumatoid oi uhrunic rhoumnlio arthritiR, n disease 
often termed rheumatic gout ; if adminutercd in this 
iiffwition their uso will uiDst probably load to disap- 
pointment. 

Frtmniis Errrhior; or. Common Anh. — ^IMffenmt 
parts of Uic Froxinus Excelsior hare at various times 
been employed in medicine ; the bnrk was extensiTely 
used in the treatment of intermittent ferera before 
the introduction of ciacliona into European practice ; 
it was also oiiipIn\'cd in iicTofiilous and gouty oSco- 
tions, and intestinal worms. It is stated also, on 
tho authority of Dr. Pougot, that the peasants of 
Anrergne have employed the leaves as a specific for 
gout for more than forty j-ears. 

M. Lame relates, that his mother was saffcring in 
1840 from a form of diseasn desigiiated by him rhca- 
matic ;;out ; she had had it for two years, and it was 
gradually increasing in severi^, accompanied with 
acute pain, much swelling, and great difficulty in 
moving the joints. After trj'ing numerous plana 
of treatment without benefit, she waa induced, on 
tho recommendation of her milUuer, to drink freely 
an infusion of ash-leaves. At the end of a fortnight she 
was relieved, and in a few months cured. M. Lame 
also states tliat in many other cases ho had tiicd osh- 
leaves, and generally with complete success. Tba 
mode in which he gave the metlicine was as a deooe-'J 
tion of from 160 to 300 grains iu about six ounces 
water, and this quantity was taken night and mo 






JAH LEATES AS A REUEDT. 



4S» 



I 



or enry Uiroo houn, aoconling to the intoiutity of the 

8}-inptO018. 

Dn. FoQgct D&il Pcjrrftud consider tho loaro* of 
Uio (uh A truo specific in tho trontmiiit of goati as 
dot only ponuring powerful curatiw propcrtia^ bat 
OM being dni'oid of nil mcouveuivnco and danger. A* 
Uw result of a leugtbeni'd t-xpcrietice, tlicy citmo to 
tho ooDcluaiuii that withiu four or five dap of their 
omploj-ntotit, the pain.*, rcduett-t, and swelling urerc 
gcnomll)' dinum«bcd, and ofWu completoly cored; 
and tliey assert that if given for eight or ten days 
ouch month, the atUtcks cam bo warded off almost 
indefinitely. 

The aboro 8tatontent« woro made in 18S2, and 
tho value of the leaves has bcoa confimAd by a M. 
MooohoD. 

I haro modo somo trials of asb-leJiTcs in oonte 
and chronic gout, employing thorn in lieu of other 
romtdieif, so a» to bo able to ascertain tlieir true ratue, 
and tlio fulluwiug is tbo ro«ult of my expL-rienco. A 
gouty patient, uboat &<> years of agd with chalky 
dopodti on Koverul parts of Ibc body, wm seized witli 
a frc^h attack, April 21th, 18&4 ; on tbo 37th of the 
month he camo under my care, having swelling, bent, 
toadenieftH, and pitting of tho loft hand, and tho email 
jointa of the fingcK and wrist ; tbo left knoo wsa alao 
inflamed, and febrile symptoms were proacnt. He 
was ordered at once to take five fluid ounces of thtf 
duooction of asb-Ieaves three times a day. On the 
SOtb, ba\'iug token the medicine regularly fin* finiy- 



4» 



TliE.lTllENT OF CHROSIC COtTT. 




eight liouni, there was no altcrntion in tlie sjmptoDM; 
the left ell)ow had bccomL' much influmod, uid the light 
ankle sightly so. Pulso 96, hard iind full; inuoh 
eturtiiig vf limbs ; furred touguL< ; Komu hotcucss of 
left cur, which was Gprinkled with nodulos of chalky 
matter ; no sleep ; bowels open from aperient medicine. 

The medicina was then changed at patient's own 
request, as ho stated that, from former experience, he 
was Bure I could give him something which would 
relieve him. I ordered a coleJiicum mixture, and the 
gout)' symptoms, within a few hours, wero brought 
under complete control. 

The second case resembles tlio first in many particu- 
lars. A man aged 38, who had flufTered from gout 
for several years, and had a few spots of urate of soda 
on the palmar surface of one indei: finger, was next 
subjected to the treatment. The attack was becoming 
much more severe, and the day previous to liis ad- 
mieaion into the hospital, one elbow bad been severely 
inflamed, in addition to the joints preriously aflfected. 
On the 27th of April he was ordered the decoction of 
aah-Ieaves, five fiuid ounces three times a day, which 
was tukcD regularly till the 2nd of May ; it appeared 
to produce some nausea, but the gouty symptom.^ 
remained ns before, and tlic itsh-leaves were conse- 
quently ordered to be discontinued, and half-drachm 
doses of ooluhiciim wine substituted. After two days 
the influiaination of the joints had considerably sub- 
aded, and iu a very short time the man was free 
from gout. 



J 



ASH LFJiTES AS A REUEDV. 



4S1 



^^^^Bmu OOBM g&vo mo littlu hope thut nsli-tcavcs 
would prove valuable in the treatment of the diacasc, 
^K and made mn doubt the titatcmeDbi which had been 
" made regarding them by Drs. Ptmgot and Pcyraud, 
bat, after administoring the remedy in cases of cbronio 
goat, I found reason to moclify somewhat my views 
of their cfficicnc)-. 

!I have always given the nsh-leavcs in combination 
irith a largo nnount of fluid, nnd am inclined to think 
that such a mode of ndministrntiou has a ponTrfbl 
tniluenoo, as is tlai ca^c witli difforoot solino imb- 
stonoca. I ordinarily prescribe than to tho fsUowiag 
manner :— • 
An ounce of the leave*, w kq>t by tho herbalist or 
druggist, sboold be boiled for ten or fifteen minutei 
in about two jNUts of water, and tho decoction taken 
in diridod doMS during the dny, about an hour be&re 
meals ; its ta»to is by no means onpolatablo, and 
ecvcrnl of my patients have drunk it instead of toost- 
I and-wnter; it is slightly bitter, and appears to inoreaae 

I the appetite njid improvo tho digestive fonctiona. 

^K If the Bsli-liMf tea does nut rcplaoo tho other liquids 
^B token during tho day, diuresis nnd diapbomis are 
^H indtuwd ; sometimM a slight action on tho bowels is 
^1 excited, but osh-leavcs given in this dilute tnrm do 
~ not ordinarily produce any decided purgative effect 

In illustration of their value, I may mention that 
I onoo ordered them far a gouty subject, who had 
I deposits upon tho ears and hands, with great rtifibon 

of the joints, and who bad for a Itmg time suffered 



I3S 



TRK.^TMENT OF CHBONIC GOUT. 



aimuully from five or six ncutc attacks of tho disorder. 
By tbo aid of this medicine ho was Ici'pt frac tram. 
gout fov more than a twelvemonth, iind able to folloi 
his usual occupation. Ho also recovered his power of 
walking, and could tako cotisiJcrablo exorcise. 

In many other cases I hovo known good results to^ 
ensue, but few patients have persevered Buffidently 
long with tbo remedy. 

As it muy ho troublesome to have the dccootjon 
daily prcptirL'd, I somutimos ordcT it iu a ooa-^ 
ocntratcd form, m that tha ^'irtues of on onnco of 
Icavets aw contained in an ounce of the concent 
decoction, and from two to three tea-spoonfuls of this" 
solution may be taken iu eight or ten fluid oanees of 
water three times a day. A small amount of ^trib 
is required to preson-e it for any length of time. 

How ash-leaves act, I am quite unable to say. Do 
they produce more effect than an equal bulk of water ? 
I believe the decoction sits more easily on the stor 
than water, and this alone is a great desideratum; it 
appears also to act as a stomachic tonic. 

In the urine of the patient above alluded to, an 
increuso of the uric acid was observed, bat 
confirmed by much furtlier cxjtcrience, I should not bal 
inclined to lay stress upon the fact, as it might harftj 
arisen from other causes. 



SlomacMc» and Tonics. — To prevent tlio undue for- 
mation of uric add in equally us impurtnnt as getting} 
rid of it when present in the blood, and wo must 



8T01IACHK-8 AND TONICflL 



193 



» 

t 

k 



ondeantur to eSect this, if posuble, by the sdoptiou 
of proper measures. This object is chiefly obtained 
by strict BttostioR to diet aiid rcgimon ; but raiuedioR 
dirooted to the restoration of the digo;<tivc oi^its atv 
o^n of muoh imi>ortnDO(!, an vru liavo hci'h t>iut iii 
the humoii subject an augiiientatiou of uric aotd i» 
intimately associated with some forms of d)'spppt<ia. 
When there Li evidence of a oougcsttro state of tlio 
liver, it must be relieved by unloading the turgid 
venels ; to e&ot this, ptu^gatiTes are DseAil, oombioed 
with small doses of oolehicum, or with minute quon* 
tides of blue pill, to produoo a chologogue action; the 
same can often be eScctcd 1>y giving toraxacam freely, 
and keeping up its action for awhile. Small doses of 
the nentriU nils may bo ncLvantag«ou«, iu conjunctioii 
with tltc lost nuxUfiioe, and if tlic patient be suSering 
from irritative dyspopsia, solution of potash may bo 
givt'U, combined with a little dilute pnisac iicid. 

If at any timo then: is much n'ant of tono in the 
stomach, bitters, and more especially those which arc 
aromatio, may bo either added to the other romcdia 
or admiimt^'rcd by themficlTca. For this purpose, 
tnfiuMnis of chamomile, calunilm, chiretta, quassia, 
•eqwntaria, cascoriUa, and like substances are in- 
dicated, «ith the occasional addition of small quon- 
titios of the titMtares of gingor or capsicum, to give 
inoraaiod stimulus to Die digestive organs ; such infu- 
stoot may. wbon od^Tutble^ bc eombinod with Iticor- 
bonato of potash, carbonate of ammonia, or bioorboiiata 
of soda. 



P V 



484 



TBKATMRST OF CHROKIC GOtT. 



"Wlicn trcutiiig of tlio use of valines, we purpowly 
ositti'd Uie om^idcrntioii of the bicarbouate of sodn, 
M it is a salt which poSiSr^ica scarcely any eolvent 
power over urate of soda, and is, therefore, iii this 
respect verj- inferior to the potash salt. Still there 
arc oiii<C-'< in wliicli bicarbonate of soda may bo u'wfiil. 
as it iigroi's with the stoinauhs of some patients better 
thnu the potash salt, oddi'd to which it seems to 
influence the accretion of tlic liver. I prcaeribe it in 
that fonn of gout which occiir.'t in full habits, when 
the kidnej-tt are but little iniplicattHl, (in<l when the 
(UatlieHis is strongly connected with derangeineot of 
the chylopoetic viscera. "Wlicn dcpoaitioDs of urate 
of soda arc rapidly taking place in and around the 
stnictores of the joints, or near the external parte of 
the body, I believe the free ejcliibition of salts of soda 
likely to add to tlie mi^cbiof. 

In connection with the treatment by tonics, it is well 
that we allude to a once celebrated prcparntion, the 
Portland I'owder, so named from its having been 
purchased by the second Duke of Portland, who, on 
account of the service it rendered him, diHlributed it« 
redpe for gencntl use. It consists of equal parts of 
the following five Bubetances : — birtliwort, gentian, 
gennander, ground-pine, and (he fops and leaves of 
the lesser centaury. Ilie dose usually prescribed was 
a drncbm, taken every mombg fasting, for three 
months ; after which it was reduced to three-quarters 
of a dracbm, for another three months; then to half 
a dndun for the remainder of the year ; after this tho 



STOMACHICS AND TOSICS. 



4U 



same dose er?ry otlier moniing for the next tvetro 
months, by which time it vnu presumed s cure would 
he accompluihcd. 

It i»u<!t oot, however, be supposed that this mode 
^oombfttiiig the tnnnptonis of chronic gout was by 
means noTcl, for wo find that very similar moans 
were adopted by the anctentfl; thus Aetios, Oolen, 
and others were in the habit of employing bitters 
nearly akin to those composing the Portland powder, 
and OsbIius Aureliauos even suspected they might do 
mischief. Sydenham likewise advises simihtr retne- 
dios, and gives a long list of plants which may be 
employed fto- the purpoee, including among them 
angelica, elecampane, me, chamomile, and juniper; 
many uf tliem in their nature not unlike those before 
enumerated. 

Hebeiden remarks, that this powder row into 
bvour too fiut and too high to keep its place, but ho 
tbonght that it had sunk into a state of discredit and 
DCgleot OS much below iU real merit as the first 
proiaos were above it He was inclined to attribute 
this neglect partly to the largeness of its dose, which 
although almost too large for any body, was indiscri- 
minately given to all, and, lastly, to its having all the 
DAtnral ill-effects of the gout attributed to it, particu- 
larly paralysis and apoplcxi,', symptoms probably duo 
to tbo diaraae itwlf. Hebordcn states that daring tbo 
great vogtio of this medicine, fits of gout were so &e* 
quently lessened, or found to mifis their osuol time of 
return, that few could have any doubt— he himself had 



r r 2 




TBEATStEST OF niRONIC QOUT. 

none— of tbo powder haring prodnoed theeo offecte ; 
wbOc iU linving uiy share ia the mischief imputed to 
it i< devoid of ccrtAin proof, and in hia opinioD of 
miu:b prolmbilit}' ; lie further remarks, "Xor indeed 
vns its difgrnco owbg to its doing too little, but to 
ito doing too much. The drend of Ix-ing cured of the 
goat 'was, and is still, irnich greater than the dread of 
having it ; and the vorld eeems agreed patiently to 
ttubmit to thin tyrant, lest u ytotm sliould come in its 
room." Ilcbi'nli-n considorcd that not lew than fifteen 
gnuns chould he given tuieo o-dny, in pepperoiitit- 
watcr, and that few would bear more tliuu a tivii- 
scniplo doto for n onlinuiinoe. 

The QM of the rortland povdor ha« been tliought 
by some phyociiuu to lead to much miwliicf ; Cullon 
states that in e\-cr^' instance in which ho bad known 
it to bo administered for the prciwribed length of tinw, 
the persons who had taken it wore nAcnrards frae 
from inflammation of the joints, but were afft-cted 
with many i^yinptom« of Uic atonic form of gout, and 
all. soon aJW finuihing their ci>ursc of the mcdiciiK^ 
wore nttadced with apoplexy, asthma, or dropay, 
whioli proved fatal. 

Dr. Cadogan likewise se^'croly censured tho use of 
tho Fortlnnd [wwder, remarking that between gflj- 
and silt)- people witli whom ho had been acquainted, 
and who bad been apparently cured by it, in leea than 
six years had uU died ; but Dr. Mason Good, in com- 
menting upon the opinion that bitters arc mischio 
fw gonty subjects, makes the following very judioi' 





POBTLAITD POTTDKn. 



43; 



remark: "As Dr. Culk'ti gives lU tio accnuut of any 
miMhicf which hiLi fulloircd thv um of bitter tDoiei in 
Gonstitutioiu inarkcd by {;cn«ral debility and ntonio 
gout, tlio cviU ho hiH doteribed sociu oti his oim 
oridcocc to be limited to thono whom vo Lavo olrciulr 
oaationecl against the employment of soeh a conne. 
No proper classification or lino of distinction seems to 
hare been dravn or adhered to, vhich would pro- 
bably hare presented ns irith very difTLTL-nt results if 
it had been, and haro supcrwdod tlio clii»hing and 
unsatififactory explanation of utonio cffecbi unifonuly 
produced by a continuance of t«nic medioinos." 

I cannot conccira thnt tho cxhilMtion of oromstio 
bitters in pro])crly Mlcctctl cases can lead to the 
oril ooRscqucnccs alluded to by CuUen and Codogan, 
but at tho Hamo time I tliink that caution should bo 
used in their exhibition. Tho more potent tonics — 
those which act on tho nervous sj'stem. and especially 
the preparations of bark — have had their advooatcs 
in tho treatmont of chronic gouL Bark has boon 
oxtnngaatly budod by somo as a curative agent, 
but othcm have oltogotbor condemned its employment 
That it is not a spoeific, experience has assured mc, 
■ad, moreover, it has often occorred to me to see a 
reoufreneo of the paroxysm follow its use, but 
whethor depoodent on tho bark, I cannot pomtivdy 
assert. Sometimes I hare given the medicine in the 
form of tho deoootion, sometimes as tho sulphato of 
quinioci 

Ono point of interest in relatioo to this subject u. 




4m 



TREATMENT OF CHRONIC GOUT. 




that quioine has been stated by Dr. Kanke to dimi- 
oish the secretion of uric acid by the kidneys ; if thw 
be the case, the dimiaatioa mufit depend either upon 
its leseening the fgnoadon of this acid in the system, 
or chocking its vxcrotion ; if the latter bo tnie, we 
should expect to find quinine and bark injuriouii in 
gouty cu£c», but if tliu lurmcr bo the explanation, 
these drugs Ehould prove of cssontiul Bciricc. I have 
ropoated Dr. Rankc's observations, but my results 
Tvero not altogether iu iicuordanco nnth those obtained 
by him. There was, however, soino difTcrcnco in the 
mode of administering the gulphato of quinioo ; he 
gave only one large dose, about fifteen grains; I 
administered the salt in diridod doses. 

In one patient, a young man, recovering from a 
slight attack of colic, the amounts of uric acid elimi- 
nated by the kidneys under the full diet of tho hos- 
pital and without motlicine, during four days, vere 
5'04 grains, 7'44 grains, 0-86 grains, and 9-22 grains. 
Tliree scvai-grain doaee of sulphate of quinine vere 
then admiuistered, and only 410 grains of uric acid 
were eliminated on tliat day ; and on the following 
four days 7'G8 grains, 7-70 grains, 6"5S grains, and 
G'oO grains were secreted. For tho next two dkys, 
six gmine of the quinine .salt were given three times 
each day, and the amounts of uric odd were S'64 
grains and 5-24 grains, and for tho following thrco 
days, 5*85 grains, G'84 grains, and 6-20 grains. It 
was only, then, on the first day, thut any KCnsible 
dimiuatioD in the secretioD of urio acid occurred ; if 



J 



EFFECTS OF QUININE ON THE CTIIC ACID. Ml> 




r 



the average pftS!«d with and without the (luiiimo be 
estimated, the figures will not be found to differ 
widely from each otter. 

Ta another case, a patient without medicine was 
pas^ng 6'03 grains and 5*33 grabs of uric aeH on 
two coBBOCutivo daj's. 'Whon takitif;; 18 grains 
of sulphate of quiuinc in divided dosos during thrco 
days, ho throw out S'58 gruiii.t, 5'7G griiiuij, and i-7G 
griiiu, Aitd tho next two days without tlto drug, 5-50 
gmiiu, (md C'C9 grniiis of uric ncid. The aTcroge 
without m«dici&c being 589 graiiu, and when quiuDO 
was talcL^, d'37 griuiiH. 

Dr. Ila»k«'!ii skill ns a ithysiohigist ia so well 
iMtabliidicd, and \m oxpcriincnt^ »u dcci^iw, that I 
should not wish for n momoiit to cast a doubt upoa 
their accurac)-, hut would rvtbcr wait the mgult of 
further obftrvatimi k-furo forming as opinion on the 
mihjoct. I cannot, however, help thinking ihnt the 
dccTTOso whicli occurs an tlio administratiiHi of tlie 
medicine in duo ratlior to a soddoD iuprsttion upon 
tlko n«r\'ou4 sy»t>.'Rt cnusiig tho quiniuo to influenco 
the excretion nf urio acid, titan to any doficocot fonn- 
•taoD of tliis priiictplc. 



The last tonica we shall refer to are the fermginoiu 
salb. 

These preparotioos when indiscriminately girea tu 
gouty suhjectft aro apt to excite paroxysms of their 
disorder, and are for the mo«t port contru-iodicatod ; 
but cases occasianally pretwnt tbenuvlvcf, accompanied 



4M 



TKEATirENT OF CUBOXIC COVT. 



■with wnnt of tone iinJ nn nnicmic state of liabit, in 
whicL their careful cxliibition is ottonded with ndviui* 
tago. Wlicn iron is needed, thowprcparatioiia should 
be selected which produce the lea^t |>oftsible dieturb- 
anco of the stomach. Cullcn preferred the rest op 
oxide ; those which I have fmind mnst beueficial are 
iron reduced by hydrogen, the Fer reduit of the Frcndi, 
or the Femim redactiim, and the carbonate of imn 
dissolved in wafer by an excess of carbonic acid. The 
citrate rif iron, combined witli Fomo saline, is likcvise 
useful. Mineral waters of the ferruginous class, as 
those of Schwallbach, Spn, Pj-rmont, may also be bene- 
ficially employed, as the largo amount of water tends 
to keep the scerptions free. It is important that great 
att«tition should be paid to the condition of the bowels 
during the exliibition of iron preparntions. 

Trcatmnit of Ooiit iehcfi afjeompntiirii tcilk Albiimi- 
iiuria. — ^^Vc have befiro had occasion to notice the 
frequency of the occurrence of a small amount of albu- 
men in the urine of patients suffcnng from gout ; this 
circumstance should bo taken into account in its treat- 
ment, ft* by BO doing wo c^an often not only afford 
great relief, but soniflimes render a diseaso tractable, 
which would otherwise prove unmanageable. Counter- 
irritation to tho loius is a remedial measure I £ro< 
fluently have recourse to in ench casoe : for this pur- 
pose I commonly ad>nso either the application of 
mustflrd poultices across the loins, or & stlmnlating 
liniment Bprinkled on impermeable cloOi. Now and 



WHEX COllPMCATED VTITH AUinilNrBCA. til 



then I proKribo iihydrogngueconipoacdnf bitartmtcof 
piFtnsh nnd juliip, niid nt tlic mme tinio diroct especial 
ntCcntion ki tlic runctitm.'; of ihe Hkiii. 

I hnro TMords of many cases in which this troat- 
inont has pmv«d most ?aluable, but will seieet only 
line for illiistr&don. 

July. 1801. — ^Thc palipiit, a man &g(A 32 wars, a 
master jilunibor aiid painter, who inbcHtod gout from 
h\» f*thcr and lum two brothers suSvring (torn the 
same diMaso, all of tlicm painters by trade. 

SoDO years tdnce he suffered from tbito or four 
■ttadts of lend oolic 

A,boat «ix years since he first expeiienccd gout ta 
one knee, soon afterwards a Accmid fit in both ankles 
and a knee ; the attadta hare latterly become so fre- 
quent tliat he lias scarcely hod ainnnth'^ interral. One 
pcouUarity of this case oonasta in the fact <if the great 
toe never baring been implicated, and another fenturo 
is the readinosfl with which the patieot is oSectcd by 
mercury. During the last two or three yoort the 
upper estrcmitice hnro boon affected, and although 
there is no marked stifiening or distortion of nny joint. 
stilt there is ertdence of deposition of urate of suda 
from the occurrence of spockd of this salt in the hcUx 
of eacli car. 

The urine is oopionfl^ dear, speeifio gTavi^ 1013, 
and contains a notable quuiti^ of albumen. 

This patient was ordered to apply ma!>tanl potitticve 
to the loins each other night, or as frequently as bo 
oould bear them; he had likewise a ealine prescribed. 



in 



TREATSrENT OF CIIBOKIC OOIT. 



imi] the result of l\iis vcr}' simple treatment wm that 
up to the present time-, Jiiite, 1862, he has remained 
free fnim auy further uttaeks : this freedom camiot bo 
ascribed to any chnugc of diet, for this patient for a 
Iimg time hiid giveu up the use of alcohol in any 
shape. I lmvi> uo ht^ititation in lutcribin)^ the great 
improv'emcnt to the inSuence of the counter-irritation 
upon the loins, relieving the renal organs. 

In connection with Uils auhjcct I may mention a. 
somewhat curious fact, namely, in certain cases, gin> 
nrhich usually has little influence in exciting gouty 
paroxj-smB, will occasionally do so when there is mueli 
renal eoinplicntiun ; this probably depends on tiia 
juniper oil or turpentine contained in the pn, causing 
irritation of the kidneys and increasing the congestion 
of those organs. 



TiTafntenf of (hf local Affection. — AVc hnro already 
shown, in our third chapter, that chronic gout is often 
attended with much loe^d mischief, which we there fiiUy 
deficrihcd. To .-nich uu extent does this somctiines 
proceed, that life may be rendered miserable. It is 
stated that in the cn.ic of the Emperor Oalbo, his 
hanib and feet wore so much distorted that he could 
neither wear a sitoe, nor even hold a ^ninll book ; and 
he is reported to have said, " Wlien I .'(tand in ncod 
of eating I have no hands ; when walking is nccc««iry 
I have no feet ; but when I am to bo tormented, then 
feet and hands are all ready." 

It has long been a prevailing opinion, not only 



J 




I 



I 



OF THE LOCAL MISCHIEF. 



U* 



amoug pliyociaiui, but the public also, tbat when 
oliaIk>' deposits appear on the surface of the body, or 
when a case is such as to be termed one of chalky gout, 
no cure con be expected. Hippocrates and Areticus 
ontortoinod this view, and Ovid has recorded the 
soma iu his opisUo from Pontos, in which it is 
Ktatcd,— 

Altdia proof that cren at no rory diistunt period the 
same opinion vas held, wc find Ilonico M'aliiLilL-, him- 
«df a suSViicr, en)-ing in odo of his lettcrti : " I hare 
M good an opinion of thu gout, that when I am told 
of an infiilliblo cure, I laugh thr proposal to teora, 
and declare I do not doslru to be cured. I am serious; 
and though I do not believe there is auy cure for that 
dLstcmpcr, I should suy the 8uinc if there were one, 
and for this reason I bcUcvo tbt> gout • remedy, not 
a disoase, and being so, no wonder there is no modi- 
eino lor it— nor do I desire to ho cnrod of a remedy." 
As tho physician is often consulted by patients 
suffering from the consequences of chronic gout, in- 
cluding not only chalk stones and alMicesaes, but 
rigidity of the joints and other scquclfc, 1 will endea- 
TOUT to explain tlio best mode of dealing witli these 
Toriotts forms of local mischief. Sydenham was of 
opinion that under tho iuiluonce of daily and long- 
continued bodily exercise, not only were tophi pre- 
vented from forming, but indurated tumours even of 
considerable standing occasionally disuppeorisl ; ut tho 




J 



444 



TBEATMEXT OF CHKOSIC GOUT. 




same time he remarks, tliat this only ensued in cases 
where tho chnlkj' tiiiiKiurs had not converted the dda 
into a Buhstaiioc like- themselves, 

BoSrhaave has an aphorism to the effect that good 
may bo done hy proper treatment, even in tho topha- 
ccoos variety of gout, and others haro entertained still 
more sanguine expoctationa from romL'diwt. 

False ideas of the composition of gouty concretions 
led at one time to the use of acid lotions, and a mix- 
ture of hydrochloric acid and oil of turpentine was 
occasionally employed. 

Alkaline remedies, however, gained most favour, 
notwithstanding that «n explanation of their value waa 
not recnncileable with tho idea of chalk-stones being 
of the same composition as bone earth, and we find 
Aetiua making use of a mixture of quicklime and 
nitre (probably an alkaline carbonate) mixed with 
lard. Tralliauus nH^a employed a similar compound, 
and Van Swieten made a composition by hcatiDg 
together crude tartar and iiuickliine, a solution of 
wliicli in water he applied to the goutj- tumoure, and 
(iKcrtcd that it was followed by mniirkubly good 
effects, and sometimes in the course of a few days by 
the total dispersion of the swelling. 

Sir C. Scudamorc, from considering the easj- solu- 
bility of uric acid in a solution of potash, was led to 
the employment of it as an external application, and 
remarks that in tbn/u instances of reeynt deposit, it 
was so successful tliat the concretions which had beim 
^isibto under the skin were gradually removed ; hs 



i 




OF THE LOCAL UISCIIIEF. 



445 



* 



* 



f 



ordcrtd tlie solution of ]K>tiuti to bo mixed with at 
lout *a oqual ijuniitity of ri'dtrntly-propaml almond 
milk, and rubbed on the [lart two or throo times a- 
day. 

WUcii chalk-stones vrerc of long rianding, ho oon- 
ndi»od tlint, although much less could be accomplished, 
still the cuo should not bo abandoDcd, and that 
even then the olkalino UDomotit migtit diminish the 
Htxc of tlio tuniour», and increase the mobility of the 
joint?. 

One of tlio more common and filighter 6«qaeliD of 
gout, if tho lofiammatiuii has lingered, b an isd«ins* 
tou.1 fltato of the limb, and this is more eqiecially smd 
in the lower extremities, and probably often proceeds 
from the vessels huWng been weakened ; occasionally, 
however, this condition is either dependent on or at 
least mu^ increased by some defect in the secreting 
power of the kidneys. 

The nxlema, if dependent on local debility, ia best 
remedied by the use of elastic stockings, conibiiMd 
with gentle friotiun with some slightly stimulating 
application, as camphorated oil ; at the same time the 
limb should be ele\'ated as much as posable on a taot- 
rost, to facilitate the free return of blood by the reins. 
If the kidneys bo in fault, a condition gencndly indi- 
cated by the presoucv of a trnoo of albumen in the 
urine, other remctlics may bo required, and tlie 
vapour or hot-air bath, aalino diapborottes; with 
gentle oounter-iiration to tlic lumbar region, an of 
groat ecrvicc. 



4U 



TIUUTMEST OF CUHONIC GOIT. 



If stifFnees of any joint be left as the rcsnl' 
gouty fit — and we linvc sei'n tliat oven partial anchy- 
losis imiy bo causLsl by a singlo nttucic — then local 
troatment must be hnd recourse to, consisting in tlie 
use of friutioii find pussivo movemtoit, but short of 
inducing tendcmc(<s of the joint. The friction may be 
fffixitecl with some simple lubricnting embrocation, 
mndc more or less irritiitiiig by mennH of ommoDi* or 
mi e-sscntial oil ; occnsionally, under these circum- 
stance?, smnll blisters are productive of much advan- 
tage. 

In using raeohnnical appliances to joints stiffened 
by gout, the cause of Rirh nudity should never be 
lost sight of, for injurj- may be induced by a too horafa 
mode of procedure; gentle means, continued over a 
lengthened period, arc most likely to be attended nrtth 
success. In such cases the use of mineral baths, as 
those of Aix-la-Chapelle, Wiesbaden, Toplitx, Buxton, 
and Yichy, are often of considerable benefit, and 
douche baths and shampooing are specially indicated. 

Now and then I have prescribed lint dipped into n 
weak solution of carbonato of potash, to be wrapped 
round the stifFcQcd joint and kept moist by oil sallc, 
and occasionally I have seen distinct relief afforded by 
this treatment - 

It must be borne in mind that the stiffiicGS and 
tenderness of the joint* is generally dependent on tiro 
combined causes, partly on the urate of soda which 
bns bcoo deposited in the ligaments, and partly on n 
chronic form of inflammation closely resembling ordi> 



i 



OF THE LOCAL MISCHIKF. 



U7 



nary inflammation, wliick is kept up by t}ie proscncc 
of the fiirci^ii matter; the latter oonditioa is oapnblo 
of n'liof by the aid of oaunt<^r-imtants and fHotion, 
combined with the tntemal uso of iodide of patasnum ; 
tlio former is difficolt to remove, but possibly the long* 
fiODtinuod use of a potash solution, or sttll better of 
one containing carbonate of lithia, might hare somfi 
power in effecting this object, especially if aided by 
the emploj-ment of properly selected internal remedies. 

Wlien chalk-stones appear on the mrfaoe, the 
<incstion of the possibility of their removal by treat- 
ment is often mooted, and the following is a summary 
of what may be done in such cases. 

When the ears of gouty patients, exhibiting the 
pearl-like nodides upon the helix, are watched, it will 
frequently bo found that in the counso of a few montha 
a condderablc change takes place, arising from tho 
falling off of old and tbo ibnnntion of new deposits, 
and this change is sometimes caused by the uninten- 
tional picking or rubbing «f tJio eare. Those concre- 
tions, it will be remembered, are produced by a liquid 
exudation into the fibro-cartilage, which afterwards 
hardens, and the integument covering the cortiLi^^ 
being thin, is easily penetrated, tliu nodulo detached, 
and a naturid curv thus effected. The ear, for 
example, represented in Ilato I., fig. 2, had under* 
gone many changes during the time the patient was 
under my own oltsorvation. If it he desirable oa 
account of the size of any such deposit to remove it 
speedily from tlic ear, this can be accomplished, if it 



*a 



TREATJIEST OF fHROSIC GOUT. 



1)0 somifluiil, by pvmctimiig with a lancet, nnd squecx- 
ing out tlio cryfitalliiiG matter by the aid of slight 
pressure ; if the concretion is older, it can ho detached 
littb liardcucd mu.S6i-j confiisting of oggK^ted 



in 



crystuhi. On account of the little susccptihilit)' of tito 
car ti> take on iuKumnmtury action, -such treatment is 
not followed by any injurious a)usciiuences. Now 
and then siu&ll tophi may bo separated in the samo 
manner from uthvr parts, hut in doing so wa should 
be careful to a-'scirtuiii if they [losacss a deep origin, as 
this circumstance greatly ioKueaccs the facility of the 
after healing. 

When concretions aro formed around joints, and 
project so us to bo of much Inconveuiencc, foi'miii^ 
tumoura more or less resembling those delineated a 
fig. 8, p. 61, and fig. 9, p. 73, it may occasionally be 
prudent to puncture them with the lancet, taking caro 
to make small incisiouB, and not tu use much subse* 
([uent pressure in removing tho croiuuy matter. Saoh 
incisions will often heal by the first intention ; if not, 
tho part may be kept moist willi wiittT-drceaiDg, or a 
bread poultice, and then after a short time allowed to 
heal. 



Occftsionalty, when incisioni) have been made, niid 
more frequently vihea the tumours have burst uf 
themselves, the sores become troublesome, and remain 
open for a long time. This obstioBdj uises from the 
deposit being deep-seated, and from it* oontiuuisg to 
approach the surface tD order to bo diiicluuged; 



OP THB LOCAL MISCHIEF. 



Hi 



I 



besides tliis, whon air has been once ttdmittod, Uie 
fomution of pus generully ensues, whicli adds to tlie 
difficolty of heiiliug. Under Uic»c tircumstaiicca the 
appliciition of iiilrate of silver is of use to restore 
Lcalthy aetion. 

Mr. Joiitos Monro, in Kb communication to the 
Modico-Cbinirgieat Society, recommends that when a 
fiuvere fit of gout attack-'^ a part in which there is an 
ttccumnlation of chnllty mutter, a warm poultice should 
lie tppHed, and if thon? be tiny threatening of gan* 
grono, which I miiy o1)«Tve very seldom happens, he 
ad\'i»cs stimulantii and upitim to bu udtniiiLitcred. If 
the cutis over a deposit <)iicn.s hut leaves the chalky 
natter eonfinod by the cuticle, lie thinks a puncture 
ehould immediiitL-ly he mode, but that it i« impnident 
to towh the skin itself witli the lancet, or even to 
mBko a krgo opening into the cuticle. Ho is also 
opposed to the use of much pressure for the purpose 
of squeezing out the gouty matter, and says that even 
a small puncture will pennit a portion of the fluid to 
escape, and that more will run out into the poultice, 
and thus the tumour ia removed, and the symptoms 
commonly improve. yVhea the inflammation has 
subsided, greater freedom can bo used ; some portioii 
of the CQticlo may be removed to facilitato the dis- 
charge, and gentle pressure also employed. If an 
ulcer has much chalky substauoc at the bottom, this 
slioold not be attempted to be got rid of by the knife, 
Bs it may cause gout, or set up inflammation, and, as 
the deposited matter is ta eepaiate cells, an ioeiaoD 



• 



450 



TREATUEST OF CHBOKIC GOCT. 



would remove but little of it. Caustics, employed 
with caudoQ, answer better, for, by dostroying the 
cellular membrane that confines the urate of soda, it 
often Eiiables it to escape. Mild dresongs only tthoold 
bo applied, as all etimulants are hurtful. It should 
be borne in mind, in order to prevent disappointmoQt, 
that these ulcers are often of long duration ; this can 
he readily understood when it is rcmcmborod that not 
unfroquently the deposit of urate of soda extends from 
the EUtface down to the joint itself, a fact rcadily 
seen on refereaca to the drawings in Phito m., figs. 2 
end 3. 

In concluding our Ttmnrks upon the local treat- 
ment of gouty chalk-stones, I may add, that it is & 
judicious rule to inteifere with them ss little as pos- 
sible by surgical means, as small advantage can be 
obtained, and great mischief occasioned. 



Diet and Regimen in Cfiroiiic Gout. — Of the im- 
portance of a regulated diet and atteatbn to 
regimen in the cure of chronic gout, in order to 
prevent tlio returns of tho disorder, there can be but 
one opinion, all experience and authoritj- arc in its 
iaToar. Galen affirmed that it was impossible to cure 
those who indulge in eating or diinking, bccauio by 
tlieir iutcmperute way of life they are constantly 
adding to tbcir didcoite, and Sydenham wisely aoid^ 
that however valuable remedies were in dironio gooti 
they were insufficient single-handed, oud need be 
accoutpaiucd with great euro iu diet; lu alluding 



J 



DIET AXD KEOIMEN. 



ttl 



paiticalarly to his own caso, ho remarked that 
tion in cetiug and dniilcing must be KtrioUy 
atttndcd to, in order that tlio atoiniich may m^civo uo 
nUBOibod thjiii it can cosily digest, uud uo fresh fuel bo 
thereby nddgd to tho diseiuK-. Sydcnlium nt tlio ftomo 
time considered tliut the opposite extreme was equally 
injurious, as he had experienced iii hLs own person ; 
for nLstinoiice, Miys he, weakens the parts, by with- 
holding from them their duo proportion of that 
ulimcat which is ucccBsary for supporting tlicir vigour 
and 8ta-ngth. Cullt'u, altltough doubting the power 
of mcdiuini.^ Utought that much might be done by 
proper attontion to regimvii, fueling fully persuaded 
that any man who commcuocd in early Life a oonstaat 
habit of bodily labour and abetioonoo from animal 
food, would bo preserved from gout, even if ho 
inherited it. 

In dironic goat the rigid diet, so neocswry in the 
acute paroxj-smii, must be replaced by one capable of 
supporting the strength of the patient; but as all 
nutrimi^ut which exceeds this is productive of injur)', 
there 19 uo Uttlo difficidty in correctly apportioning 
tho food. lu ttnpcct tu tliis point no better rule eau 
bo laid down to the gouty eubjoct than that of Sir 
WiUiam Temple, who remarks, " Simple diet, limited 
by ever)' man's experience to his own easy digestioOi 
tad thorvby proportiomng as near as ciin be the daily 
r^Mlis to tho doily decays of our wasting q-stem." 

As the exaecrbatiuns of gout abate, the diet may bo 
gruduuUy improved ; some of the farinaceous matter 



M 




TnEATMEirr or outonc oomr. 



Kptued bjr frriit, SA, or fowl, and ■fkenrntrds by 
meat ; it is of much ootueqncnoc to aniid all tndi- 
gestiUe didie^ and tgpemXiy mob u oontain fiw 
■adi, M IheM ara apt to «aaa9 a noonwum of tlu 
parwyi B. The aae of an ndnsfcly vagotable ' 
hai oecoBonally bean neonnendcd in the treatni 
of gont, aad earw haro baeo related in which, b; iti 
omployinoDt akoBe, patienta were not only ki-pt frw 
fiam inftoBnMlorjr symptono, liit their chnlk-stunei 
hare alio diaappcaied ; noHrith$tsnding this impnrve- 
meni, n H'turn to an animal diet was immediately 
bOowod by an acccsaun of th« disorder. Experienee 
baa dearly shown, that gout cannot be saccefHTully 
treated by abstinettGo Jrom meat, allhough a oarefid 
TOetriotion aa to qaantit>', no as not to cxoood that 
wbioh ia necoMaty for the pruper Kwdcnoooo of the 
body, is of mueb imju^rtaiico. Examplee are not 
wantinf; in which gouty persons have entirely ns 
gainixl thrir hoalth by hdag reduced to -poverty, and 
obliged by daQy hdwar to gain a spare Eustenanoe ; 
•ad Comam a aaid to ba>'e freed himself from gout 
and to have lired to be a huDdrcd, by diet alone, 
«Ilhou)fh he did not oommenco his change of li^'ing 
until lie was mote than forty yoam old. Such a 
•uddeo change, although occasionally suoooMfbl, would, 
in many inirtanoes, bring on a paroxysm of the diaeaat^ 
and not unfreqaently be dangerous. 

One of the boet methods of limiting the quantity of 
animal food is to make the number of dishes few, as 
tnixturcti of different moats are not only mote difficult 



DIET AND RIKIMF_V. 



40$ 



I 



of <lig«stion tliuQ an equal quantity of one ^art, but 
tiie appetite, wliiii tenipt^^d, often deaires muro than 
tlic stnoaitcli u cnpablo of digesting proporljr. 

The m<wt digestible meats, as mutton, well kept 
bcof, and poultrj% uHth the wliito kinds of &sh, as cod- 
fish, title, and whiting, may bo partakon of; Mhnon, 
real, and pork shuuld bo avoidt.'d, us wvU as salted 
meutat ohoecOt and niw vcgi'tublt-^ whicb, u'ith highly 
seaaoned diabce and rich muixs, am Ukvly to induco 
dj'spepsiB. 

Potatoes, valuable in giving constituctitl to the 
blood which am essential to its healthy compontlOD, 
aa llkeirisc boilod greeofi, turnips and carrots, may be 
eat«D sparingly. 

All Htonu fruits, applM and pean. unlooa baked, 
dhotdd bo ignored, but strawberries, gntpcs, onuogei^ 
and other iniceulcut fruit« may be enjoyed in modera- 
tion. Stiawbrrritis wcro eviii stated by linuaeus to 
prevent tho occurrenco of gouty attacks when habi- 
tually taken. Sub-ucid fruits owe tlioir efiicucy to tho 
alkaline Bolts thvy contiun, which ore di-composcd in 
the blood, and appear in the arino chiefly in the fonn 
of oarbouate of potash, and thus stimulate tha kidneys 
to increased action. 

Kot only tho dtanictcr of tlic diet, but the tioio of 
taking food must bo regulated ; it i» di^tnible, if poe> 
nUe, that tho gouty man should dino in iho middle 
of tho day, or not later than three or four o'dook ; 
browu meat sliould bo token at that time only, except 
when drcumabiaeei render it« more frequent exhibi- 



IN 



TREATUSin' or CHK0^'1C aouT. 



tion ndvigiiblo, and lat<! euppci* sliould t>o avoidod. 
In speaking of animal food, I uroutd not include either 
an egg at breakfast, when it agr«t-s with thv stoninobr 
or in some cbMW a small niflicr of broilvd bAOon, con- 
fiiUy avoiding th« lean portion, which is of difficult 
digestion on nocoitnt of ita bBidfined fibre 

Wine and mult liquors must n»t be allowed ; if 
aloohol iu any form ho nMjuisitc, a little weak bmodj-, 
Vrhiakcr, or gin and <>ratcr may be taken ; it id &«• 
qucntly neoceaary to make exooptionH, as from long 
liabit some stimulus may be oascntial to tlio propur 
))erf(irmanco of digestion ; in such instances, a Uttlo 
sound Bherrr, as Amontilado, or Hanxinilla, is bctt 
port wine should bo absolutely forbidden, and exoepl 
in i>cculiur idiosj-ucracics, Ilocks, MiMt'lle, clarpts, and 
similar wines should be shunned, but it now and tbrn 
occurs that these latter wines agree with the patient 
better than sherry, and the snnio remark ap|>lica to 
good Miideira. It is of the greatest moment in all oascfl, 
that the patient should obscrre rxtrvmo modemtioa ; 
ODO or two glosses of wino taken witli tlio principal 
meal is generally sufficient, but Uic amount cannot 
always be specified, and must noocflsarily depend, not 
only on former habits of life, but also upon the ago 
and strength of tlie patient, and other constitutional 
peculinrities. 

Sydenham, in alluding to this subject, says tlint at 
least the first part of tlie old saw is true, " If yon 
drink wine you have the gi>ut, if you do not drink 
wine the gout will have you." 




DICT AND REOIMEX. 



4S5 



I 



The olij«ctiom to the use of malt liqunra, as &]o, 
boer. Mid porter, are equally strong, if not stronger 
thsti thoflo which atc urged against vine. I hare 
known several patients in whom the attacks were 
much prolonged by their partaking of &uoh bercragcs; 
and not only docs it Icngtlicn the parox>'!>nis of chronic 
goat> bnt gives n great tendency to their return. I 
romomber a gontlemmi who wta experiencing attacks 
orerjr six or eight week^ who simply by avoiding pale 
al« kept thorn off for mora than a year, and rorao of 
thfi moHt chronic and invctorat^^ ca»r'.4 I hitvn ever 
mot with, have been in pcrsonei who had brought 
OD the disease solely by the oae of strong malt 
liqoors. It is by no means unusual to find audi 
instoDcos among the men connected with ]arg;c 
breweries. ^Vllen tn the leant degree hard or 
acid, malt liquors act powerfully in exciting tlie goutj' 
paroxysm. 

Milk has been especially recommended for the 
goat)', and it might naturally be supposed that from 
its nutritive powers and nnirritating natoro, it wotUd 
prove beneficial It appears that in many casea n 
milk diet has been of much service, especially in 
the young and rtrong, but in some instances it has 
ontin-ly failed, and in old people its adoption may do 
harm. Sydenham remarks with regard to a milk 
diet that " It has done good as long as it has been 
rigidly attended to ; the moment, however, that the 
patioDt swerves from it u hair's broadtli, and the 
moment ho betakes hlnuclf to the diet of a healthy 



4S« 



TBEATMEST OF CHHONIC COOT. 



man (no matter how mild and nniplo)) tho gout 
returns worse tlmn ever." 

Of tea and cofTco in gouty ciu«s little need b« said, 
they should he tukcn in modcrKtioa and not too 
strong ; if they cause indigcstion, as is eometimos the 
esse, cocoa nny be substituted fur them. It luut been 
suggested that coffee may postess Uio power of pre* 
Tenting gout, seeing that in countries where it is 
eztennrcly drunk, as in Turkey, gout ia scarcely 
known ; but it mu»t he rcmombercd tliat in meh 
countries, littlo wine or molt liquors are token, and 
tliis fact would ^atiiifftctorily explain the exemption 
from tho disea.ie. Tlie samo may be oaid of too, 
and of tho exemption from gout attributed to tho 
Chinese. 

Exercise ia most important in gout, as inactivity 
tends powerfully to engender a stato of system leading 
to its renewal ; in tho chronic form it is of great 
mometit, and likewise in the intervals between the 
attacks. Sydeoham's opinion of exercise is frf^ncntly 
expressed in his treatise, and in one passage ho saji^ 
" Uoreorer, much ae tho pain and the great inaptitade 
for motion may seem to contru-indicato that remedy 
which I have so much extolled — exercise — it must 
still be undergone ; since, although at the beginning 
of a fit it may appar impossible for the patient c 
to ho carried to hii carriage, much less to bear 
motion of it, ho will nevertheless, provided he 
the attempt, in a short time feel as littlo pain w! 
driven about in his coach, us when seated in 








DIKT AND QKCtMEX. 



*5; 



P 



clbow-chftir nt home." And itguiii, " In rcspcot to the 
kind of fscroieiC, ndiiig on horscbnok, unites forbiddtii 
cither by old ago or » ciilcultui, is by far Uio best. 
I»dc«d, I havt! often tliougUt witliin niysi'lf, that if 
any person knew a reiiK-dy iif which ho wished to 
make » secret, oquully ofiioacitius in gout, us riding, or 
regular and steady ridbg on horseback, he might 
make a fortune." 

For exercise to be iiaofid in gout it should be 
moderate and regular ; if excessive at any one time, it 
may produw injun.', iitul, if not regular, or if H» cSbcts 
on the sj-stem bi- nut kept uj), it is of little value. Foot 
and horw exerciwi^ are both goud, carriage exerdao 
less 80, bat still of much adviuitage when the others 
cannot he employi'd, Prictiou may oceosionally bo 
substituted fur exercise when the latter eaiinot be 
taken to a Bufficicnt extent. Sir William Tomplo 
remarked, that no one need liavo gout who eould 
afford a ela^'o to rub him ; without going to this 
length, it is ecrtoin that no tnconsidorable advantage 
may bo tliu» obtained. 

In oil ciises the amiiunt of exercise ma^t bo oaro- 
folly appi>rtti>ncd to the ago and strength of the 
patient ; although exercise has been occasionally ad- 
risod and oven practised at the oommsncemcnt of a 
gouty fit, as in tlic ojtv) related by Van Swieten of a 
dancing master, who, having suffered twenty years 
from gout, kept his joints free from stiffness by getting 
out of bod and walking about as much as ho could the 
moment he perceived the least rcmissdon of pain, and 



in 



TEEATHElfT Of CHBOSIC OOCT, 



continaed this orsry day,— still the pniotieo is not 
unaUcndcid with daoger, and cannot be recominentleJ ; 
bondoB whicih fev patio&ts tua be fimnd having tbo 
monl ooarngo to pontic it. 

^mfa air is higMy vnlunble, espcculljr to those of 
vcdc btbit ; somctimcfl, when rU other remcdini and 
diotetio means liavo fnilod, fireeh air has effected tho 
desired object. A bracing air, sdcIi as is obtained in 
filonted localitiwr is jwctilLnrly admntngeoos to manr 
meh suljocts, and probably part of the benefit derired 
from A sojuuni at mineral qirings thus situated is duo 
to tbiaoaoM 

In certain cases* vhon tho nttackn are peouHarlj^ 
dcpcndont on tlto state of tho Bkiii and rcfldily 
excited bylho bleak oast and uortli-osut winds, change 
to a warmer clinutte becomes desirable, and tho inter> 
Tals of the lita may often by tbia means be occasion- 
ally greatly lengthened. Instances indeed hnvo boos 
known in which & completo ohange of residenoo to a 
warmer locality has altogether proTentcd the retams 
of gout, and from my own experience I feel assured 
that this step is o^en most lieoefioia]. Although gout 
is not vorj- pre\-alont among Europeans in India, still 
the influence of a change of climate will by no meana 
permit immoderate indulgcuoo, and in proof of this it 
will be found that gout Is not unoommon in our own 
aimy in the East 

irpper Egypt and Malta are farourable places for 
rendence during the winter and early spring ; somo 
parts of Italy and Spain are also well fitted for gou^ 



DIET A^'n RROIMEN'. 



4» 




Itstivnts; but the Bolectinn of the looalitr mast 
dopeDd much on the peculmritics of the crbc, 03 a 
climate Tound boncficial to one pcnton mtiy occasion* 
ally ho productive of ill consequenco to another; 
a circumstance easily explained by the fiicts before 
iTanced conccrmog the nature and causes of the 
isordcr. Bxerclse, fh«h air, and change of 
climate produce their beneficial effects by giving tone 
to tho stomach and digci^tive procces, by increasing 
the function!) of tho different secreting oigans, and at 
the same time by imparting strt-ngth both to the 
uerrous and miL<cu1ar sj'sti'me>. 

The cutancouH function must not be neglected 
either during tho cxistouco or in the interval of chro- 
nic gout ! the clothing should bo sufficiently warm to 
ensure tlio $urfuuo from bcin^ chilk-d, and the foct 
should bo particularly protrotcd ; flannel slitiuld be 
worn next the nkin, and likewise woollen stocldn^^s, 
but any undue warmth or ororheating of the body 
carefully guarded agftiost Tho action of the ekut 
may at timca be advantageously excited by wann 
baths, by sponging tlio body witli tepid water, or 
stQi better, with salt or sea water, followed by 
fiietion with a coarse towel. The importonoe of 
a proper attention to tho sldn will be at onoc 
Qvidont, when wo reflect that it is by means of this 
surface that much acid matter is constantly excreted, 
and that when tho cutaneous function is suppressed 
the blood becomes l«ea alkolinci and a fit of gout may 
bo thereby occasioned : for this reason cold oftoa acts 



4M 



TBKATllENT OP CllROSlC GODT. 



» an exciting eauso of gout, and warmth Usada to 
watd off tli« (liseoeo. 

LasUy, the influence of the mind od the dovclop- 
mcnt of gout must not be lost sight of. Any mcnt 
disturbaiioo tending to depress the nervous 
is certain to be followed bj- injorknis oanaeqaenoei 
gtmty 6ubj<>ctB, and it is tlit^orc of great moi 
in tho trcatinont of gout, tluit nil such influc 
should be carefully arotdud, and tlio tmnquilUt}' of th«^ 
mind *» much ru poteiblo ensured. Fur this purpow 
lato hours sliould be iJiuiinod, study and tho cok** of 
businefla laid anidc, and llio mind employed with 
ploanutt thoughto and occupations, llio foot tliut 
prolonged monlul exertion of any kind powerfully 
nfiiBots botli tli« oMitniUttng and digesthre fiinot 
u ««U eetablinbod, and that such mast DooeasariljJ 
exert a baneful iiiHunico on Uie progress of goat 
offieotioDS is equally oortnin. Sudden and violeni 
emotions haro ocenaonoUy heon fallowed by aa^ 
instantaneous relief of Ihc piiroxj'sm, but tliey 
likewise apt to prow ilangennm and should bo carc-^ 
fully guarded ngainnt. In illustration of the effect 
occasionally pn>ducod by violent mental emotion, I 
may instance the ca.sc of a man recently ondor my 
care, who, when euficring severely Irom a third 
attack of goat, hod a quarrel, leading to blows : 
the intense effort appeared to cause the rapid subsi- 
dence of the gouty inflammation, and tlic patie 
afterwards remained free from the diacaso for seTc 
jotm. 



DIET AK1> RKGIMEK. 



Ml 



b 



In concluding my remarlui on the management of 
dironio gout, it may bo desirable to give a brief 
summary of tho principal indications necgjsaiy to be 
fulfilled. 

First, to treat tbe dironic inflammation of ihe 
joints by means less heroic than those employed in 
the acufo disorder. 

Secondly, to rondor tho blood pure by augmenting 
the various secreting organs, more eepecially the kid- 
neys and sldn. 

Thirdly, to restore the power of tho stomach, 
which is usually much impaired in chruuic gout. 

Fourthly, to treat tlie local mischief which long- 
continued inflammation is certain to produce in tho 
articular structures ; and 

Lastly, to regulate carefully the diet, and pay 
sulfiolcut ttttentiou to other regimenal means. 



103 



TRliATlEEST OF OOCT. 



CHAPTER XIU. 



Tdbatukxi or Qdut : ^ utituiii witkiu— ctaxniL aRUiKEa »■ 
TiiKia KHPLomviir — jlkauxe watim or Tiont—aovi or 
AiTTiQS or— innoB's junuioaa cr tiitiB vuca— uuvc 

WitlllS OF WIEiE*DI» — THEIR VALUE IE (OITT IDLFIIDMni^ 

M1.I1B UlTEPd or ItX-l.k'OUlPMLI.R— >ErMIKI)ir IS soirrT 

CUE!— UTHU SP&IHUa OF BU>EB'BU>IE HitH II aOITTT OiaO 

ClKLaiUD VAIEU — IMLIUMCR OV UI^IEKIL WITEKJ COEtAinBa 
LltTLE SIMEE HITTER, jLl Ot WILDDID, TEI'LITI, PDXTtlV, ItC. 
— SUUIUBT tir THE TRKITHEUT Uf 40UT Ur KI.IEUb *t 



i 



Fbom tiie opinion expressed in the prvocding 
pogos, of the dfioacf of dilute 8&linc eolutioos in 
the treatment of chronic gout, it will bo no innttttr of 
surpiise, that the subject of mineral waters Nhotild bo 
next discussed. The reputation which many of tiioso 
waters have acquired, shown by the largo number of 
patients who annually resort to the diifc'rcnt .springs, 
will sufficiently justify our devoting sumo short space 
to the consideratiau of some uf tbo most important of 
thoiiii 

jVll mincift] watora poBse«.H on« action in common, 
derived from thu influcroo of the water itself, and it is 
a well cstablishwl fact, that this agent, when absorbed 
in largo quuntitiee, powerfully stimalates the proccescA 
of the animal economy, and increases the Tarious 
secretions. In lc»is important respects, mineral waters 
differ coDiudcrably firum each other; tlioso which 





MISERAL WATERS. 



«» 



k 



contain iron augment tiio Hood oorpiuclcs snd re- 
store the impoverished blood of onicmia ; those rich 
in sulphur in the form of sulphides, bare their action 
opccioUy directed to thu sliin ; when sulphates of 
suda iiiid mtiguct^u arc Uie prepundi-ratiiig iiign'ditiuts, 
tho intestinal canal is peculiarly iiiRuciiccd and purg- 
ing produced ; lastly, when tho alkaline citrbonateB 
form the principal oon^ititucuts, tho reaction of the 
socTCtions bccoDii^ »oiiKihly affected, and tho compo«n- 
lion of tlie blood materially altered. 

The mineral waters employed in tho treatment of 
gout differ very considerably ; some owe their tliora- 
pcutic valuo to tlic nature of their sidino ingn.'dic&ts ; 
others may be looked upon cliouucuUy as almost inert, 
except from tho water in their compositioQ ; many 
owe port of tlicir ctKcucy to elevated temperature. 

Among tho first class may lo reckoned the springs 
of Vichy, Wiesbaden, Aix-Iu-ChapoUc, and Carlsbad ; 
among the second, thoso of Wildbad, Teplitx, Gos- 
tein, Buxton and Bnth. It muy be observed that 
sorcrol of these latter sjiringa are situated higlt above 
tho IcTol of tlio Bea, and probably the pure and 
brocing air of these localities, tho deeper inspiration 
which it occaaions, and the stimulation of the system 
thereby induced, may give rise to much of tho im- 
prowment in patients who resort thither for tho resto- 
ration of Uicir health. 



JfiNnn/ Springt 0/ Vicht/ (Franco). — Ab Vichy is 
modi nwTt«d to, sot only by goaty invalids of 



«i 



TBEATMENT OP COUT. 



Pnuioa Mid many other parte of the Cootinnit, bat 
of England also, and ns Uw waters an uni>orted into 
Uiis country aiid artifieiaUy proparod hero, it it a 
matter of iin{>artancfi that wo should investigate the 
Toloo in tho tieatment of gout, and the anos 
adl^tod for their adminiatratiou ; for it vill be fouud' 
&at these waters arc oscccdingly powerful, and, wlion 
injudiciounly token, capablo of producing wry : 
«hiovoua offects. An c-Uborato analysis of the waten^ 
ftom the many difTercnt sources of Vichy and its 
•nrironfl, will be found in a Table in the Appendix, 
from which it may bo gathered that they 
eadiotlicr very closely in composition; thathicarboiut^ 
of soda fonns their chief iu}px'di(»it, AYCiaging itbout 
forty groins to tho imperial pint ; and tliat the othecl 
carbonatoe, although tho)* aujj^mont the alkali&o pr»>j 
porty of tho watorB, aio but of eooondaiy import- 
ance. Tho water fixim tho Grande Grillo and 
H6pital is hut, from tho other sources it is cold or 
nearly so. 

Bicarbonate of soda, when thus administered, be- 
oomes rapidly absorbed into the blood, exalts tta 
natural alkalinity, and, if long continued, caoses a 
spocica of twlutiou of the blood, and hence medieinai • 
of this class have been called SmdiliorH, antiploetios,] 
and deobstruents. iVil. Trousseau and Pidoux, m\ 
their "Traits dc Thi^rapcutique," assert that they 
have noticed ill offects resulting from the aboso ofn 
alkalies taken in the form both of Vichy and CarUbadl 
waters. Dr. Petit speaks of their neutralising tiio 




UINEKAL WATERS OF VICHY. 



<«S 



urio acid in the blood, or rendering it wlublo by tho 
formation of an urato, but tJtis is tividently urn crruncous 
idea, for we have proved osperimentally that urnto 
of soda always exists in the blood. The pi'caenco of 
soda in the system in incrosificd quantities appears to 
affect especially tho functioa of tho liver, and to restore 
it to a healthy state ; this may partly be explained by 
the fact, tliat Uio bile itself is a species of soda miU, 
consisting essentially of two organic acidii, the glyC4)- 
and tauro-oholio addfl united with soda ; and as gout^ 
or at least tlio diathesis leading to its production, is 
often dawly connected with deranged hepatic fimo- 
tion, improvement may be expected when this is 
ameliorated. 

The effect of the Vichy waters on tho urino ts 
readily recognizable. M. d'Arcet, who made numy 
observations on this subject, states that one glass, 
containing about liileen grains of bicarbonate of soda, 
when taken in Uio morning fasting, is not snfllaeDt 
to render tho urino alkaline, although it sensibly 
diminish ea itfi acid reaction ; when two glasses ore 
taken under the same circumstauces, the anno 
quickly becomes alkaliov, but remains clear, and 
that passed during tho subsequent eight or nine 
hours has the same characters, after which time it 
're-ooquircs its natural acidity ; three or more glasses 
of Vichy water cause tho urine to continue alkalina 
for twenty-four hours, the transparency of the fluid 
remaining as in health. 

Whoa the Vichy waters are employed in tho form 



8 s 



m 



TREATMKST OF C.OUT. 



enly 



of tbe bath, roilnciis nod slight in-itiition of the skin 
linblc to be produci'd, especially if the waters be 
dUulcd. 

Wc hnvu cvidviico that saline matters are ahsorbcd 
by the skin with great fucility, from the fact that one 
bath is usunlly sufficient to ix-ndcr the urine alkaline, 
even witliout thp int<'niiil oxhibition of tlic waton; 
this hn« boon stated ti> be the case by MM. d'Areci, 
Chevnllii-r, anti Dr. Petit. ^ 

Wlien at Viohy I made an observation confirmii^P^ 
the truth of this statement, taking a bath for twenty 
minutes cnmpnscd of equal parts of Viohy and o; 
nary wafer. The urine before entering the bath 
strongly acid, but on leaving it, Uio alkaline rcaotioo 
was veil marked and remained so for more than an 
hour. Tim alkalization of the urine has usually been 
Mgardod a-i a decided proof of the absorption of 
Boda stilt by the skin ; but it iH right to men 
that tho same cSbot has been assorted to bo 
duced by an ordinary warm bath, and this has 
ascribed to tho inoreased action of the skin, on 
an nugiiicnti'J elimination of the natural acid sccrotiaii. 

Dr. Parkes bas collocted the observations of nome- 
lons experimenters on this point, and from (hc«e H I 
would appear that very few saline subetancea are 
absorbed by the skin during the vse of the bath ; i t' i 
teems likewise that there is ahnast invariably a vcfj^H 
distinct loBsening of the acidity of the urine fron^^ 
the uso of tho batli, evfu when free nitric acid is 
contained in it From these obserratioos Dr. Parkos 





MINERAL WATERS OF VICin'. 



m 



is inoHncd to ttiink that wrikrs in genoral hnvo been 
too rwidy to admit the pnasa^ of sniiuc sulwtancea 
through the human ekio. I hnvo, however, found 
distbot cridcnoo of iodine in ttic urino oftor tho uho 
of « lotion oontainiug tlio oomiioand tincture uf that 
Buh-itancc, and haro aliio eoen t<7mptoma of iodiinn pro- 
doocd by the external use of the eame tincture. The 
whole eubjeot d^eires much further investigation. 

Various mucous membranes, especially that of tho 
bladder, ore also influenced, and the mucus tmm 
tlwin becomes lees tenacious, and often diminished in 
quantity. The perflpiration has likewise been sup- 
posed to undergo a change in reaction; Uie bowels are 
seldom influenced, unleM the waters are improperly 
administered. 

For the first few days when taking tho waters, few 
symptoms are observed, hut occiwionnlly patients 
eomplain of some vearinnw of the limbs, weight oo 
the head, and a feeling not unlike a slight spproneh 
to intoxioation aeeomi)anied witli a desire for sleep, 
and sometimes there is an increase in the disease for 
which tho treatment has been adopted. These first 
phenomena are not considered of any tmportanco, 
for if the medication bo continued, they often disap- 
pear and are soocccded by a feeling of incroftsod 
rigour. 

If tho Mme tjmjAomB rc4nm after the frf^atment 
has been parsood f(>r some time, their signiJcanoe is 
much greater, as they indicate a condition of satura- 
tion of (he whole system, and the amount of tho 

■ ■ 8 



tofcti 





^ 



tebten ^H* 

«f At hi* Dl^ 

KidKtt iMpadtnr at TKhjr : «■ ibl ] 

• dMT ad MBfli SbIc brcmaB* 

Di^ FMit aaanian fhift lU nln mar b* cb- 

poytd VMM K fit 01 pNit n n^MBO^ BBll CTBB Wnctt 

it bw b(«ni to dsvtiop tett Bad he ihida that the 
■nsBpHi3nif fanr, n ■nixf oepnoBBt on the aiti- 
flHif afertwai^ aDd la no waj omHlsd witli ai^ 
dneate of the organs of tht dtHt or ■*■*— "w, smI 
Bot be regarded m a cootn-iBfioidiaa. Howvm, 
thcT« are eotani pa t iro t B who an very maoopCihUk 
■Dd to whata the toletanoe ibr the mtcn dunimdiM 
or entirely ocaiKo when an attack of aeote goat aftate 
the joint*; in each cases it is right cither greatly to 
deerease or altogether to nupcad the use <^ the waters. 
On the decline of the St it is also ntxessaiy to act with 
inach prudence, for fear of reprodactng the attack; 
active treatment shoold not be reoommeaDoed too 
■oon, and it is eepecially nceeawTy to avoid the oady 

lof the bath. 

The rewlti olrtAined from the waters are much more 



MINERAL WATEBa OF VICHT. 



449 



prompt, more oomplc4&, and coDscquently- more strikmg, 
in acutfl than in clu-otiic goat, when th? intervals arc 
short, and when the treatment most bo long peree- 
Tered with, in order to give any Lopo of puticnta 
regaining tlic use of their joints, and even then the 
advantage ia hy no meims certain. During a coarse 
of treatment in chronic oases, the difiea^e may ooca- 
nonally assume an acute character, hut this ts not 
et»ciiti&] for the success of the cure. 

Dr. Petit con^dcrs that chalk-stones ore occa- 
sionally ah^rbed, although this is n niro oocuircnce, 
bat he thinks that when patients arc submitted to the 
alkaline treatmont, and this is porscvcred in for a. long 
time, it is rare thiit now coacrotions are formod. 

The oBcct of the Vichy trcutinunt is to diminish 
the violence of the fit, and somewhat abridge its 
daratioD, but its chief object us to combat tho pioxi- 
mato cause of tho disease, and prevent its return. 

Dr. Petit remarks that, as a rule, the Ticby waters 
agree well with the gouty, but he advises moderate 
doses to be oommenced with, as five or six glasses per 
diem, and the adminl-strution of a bath. If those be 
easily supported, the number of glasses may be ia- 
oreaAcd to twelve or fifteen. Some patients have 
taken aa many aa twen^-, or oven fivc-and-twenty 
gtaaei, wiUiout inconvenience, imagining that if relief 
be obtained from small quantities, much moro advan- 
tage will aecme from larger, and ao the prescribed 
amount is oAcn exceeded. Certain individuals have 
been known to drink thirty, forty, and fiity ^ossoa 




m 



TB£ATMBXT OP OOVT. 



per dicoo, uid it wbb affirmed by oao genUcnuia, 
ohltougb tlw sUU-mvnt uiQ ecarocly bo credited, that 
ho bid takoo w nuuiy as eighty-four glassea in the 
twuDty-fnur bourt. 

Dr. Petit ouiuidcn titat the vatore of Yiohy owe 
their efficacy in gout to tho &et of their containing 
much fiodu, and that other waters simiUrly ooiistitut«d 
would have tho same ralue. Ho olen thinlu that as 
the waters contain the soda in tho fonn of the bicar- 
boBat«, thoy an) useful when taken at a dtstanco from 
their wuioo ; but that, aa a rule, tfacy do not at ao 
fluUy on tho Htomitoh and cannot be taken in so largo 
qoaittilitii an at tho springa. 

Buriug the G»t and second yeont of treatment, full 
eaturation of tho patient is considcrtd of advaatagr, 
imd iiir thi£ purpow at leasi a month's exhibition of 
tbo mien in necessary- ; oonsidoraUc beneiit is often , 
obtained from, prolonging the treatment eren bo} 
that time, especially if stiffGimig or Emchylosis of tbo 
joints is present. 

Patients oooaaonally experience a repngnaDoo for th> 
wat«r9, aocompaniod with want of sleep, and a fo 
of agitation, and sometimes this is «hi>wn at an eaAf 
period of their exhibitian ; when it occurs tlio troafansnt 
mobt bo at once disoontinucd. 

Having thus exposed tlic principal views on the 
treatment of gout by Uio uio of tho Vichy waters hald 
by Dr. Charles I'vtit, a gontloman who liad abundant 
opportunities cf bcooioiiig thoroughly remd in the 
subject, it is only right to obscrre that his opinio 



MIKEKAI. WATERS OF VICHY. 



in 



I 



are not generally roceivccl oven by French plivHicians : 
for example. Dr. Durand Fardd, Inspector uf tho 
Sources of HauUtrino near Vicliy, who has also written 
on the euhject, differs considerably from Dr. Petit on 
a<!vcral imporiuut poiutjt ; for, althougli he ix fully of 
opinion that much buuefit is oftou derived from tho 
mv of the VicUy wiitoivi iu gout, luid thut if they do 
not cure tlic di»c!U8c, still they cscrl a ftiilutory iiiflu> 
enoo upon the general health, as well as en the 
symptoms of the malady, ho nevertheless considers 
that their exhibition demands much caution. Dr. 
Darand Fardel believett tlint Viohy waters do not cure 
gout by specially influencing tlie urio acid, but merely 
by producing an alterative effect. As the mineral 
waUirs act as general excitants to the whole organisa- 
taon, and cepecially to the secreting orgiiDS, he thinks 
they should only be employed under wrtuin vircum- 
sfances, which may be thus briefly stated. 

Thoy should not bo taken either when a lit of gout 
is tbrcabeaed or at its commi-neement, or during its 
continuance, or afler itii decline, until we arc fully 
asnirod that it has oomplotoly passed off. 

The time most tarouiablo for the exhibition of 
tbOH watcnt is during complete freedom from the 
attacks. 

Thero arc several cMM on rcoord of goaty suhjeots 
having died suddenly soon after commencing tho 
Tichy treatment, but these patieatM weru sufienng 
not only from guut but likewise from organic di^aso 
uf CQBU) important organ. Sometimes the disorder 



^73 TKKATMENT OP OOOT. 

appears to tave boon rendered moro dironic, and 
sufGcicnt evidence of the occurmico of ill effocts has 
been given to make it advisable to use grtat caution, 
not only in the mode of tlie employment of the 
w&t«nt, but likewise in the selection of tLo CMC& 

Having si'en cuscs of gout exhibiting cmy vnrie^ 
of phase, in which Vichy waters have bci-n employed, 
and having witnessed the plan of treatment adopted at 
the baths, I feel entitled to give an opinion upon the 
subject. Vichy waters are undoubtedly agents which 
powerfully influence the whole economy, and alter the 
character of the animal fluids, and, if they are 
capable of effecting good, they arc Ukewiec capable of 
oaufing much evil. 

With regard to tiieir exhibition is goat, I oonador 
them to be often injurious in chronic co^ee, especially 
when tho system is aln^ady lowered, and the rapid 
formation of urate dci>oi<it« is taking place cither m 
the joints or upon the service of the body, I believe 
that Uioy eometimos increase tbi^se deposits, and stiU 
fiirthor depress ilie xHtal powers. I also think that 
the constitution of Vichy waters is not such as to 
render them desirable for Uie majoritj* of gouty cases, 
inasmuch as an excess of carbonate of eoda rather tends 
to diminish than augment the Bolubilitj* of urate of 
soda, which is alwaj's present in the blood in these 
subjects. In many Ibrms of chronic gout the baths 
arc u«cful, but then their value is independent of any 
pecnliarity in thoir composition. 

In aoutc gout Vichy water, taken in moderate 



I 




MISER.VL WATERS OF WraSIUDEN. t7» 

litics, oitlior during the- attack, or when a St u 
impcnclbg, or on its decline, is not likely to do hann, 
but the use of the bath in reiy hazardous, nod should 
spver be risked ; I am confideot tltat when acute 
infiammatioa is prceeot, other treatment is more 
appropriate. 

In the complete inten-als of acuto gout, and more 
especially in strong and robust subjects, when the 
disease depends rather on increased formation than 
defectiro elimination of uric acid, and likewise in cases 
in vhich the li^-cr and digestive functions axe oon- 
Bidcmbly at fault, the cmploj-ment of theee waters is 
likely to prove most beneficial ; in other forms of goat 
mineral vraters of a different class may be resorted to 
with great<T advantage than those of Vichy. 



3Blierat rprinfft of Wlt^avien (Tfaagau). The phy- 
ncal and chemical characters of the Wiesbaden waters 
may be ropn-sonted by those of the Kochbrunnen 
spring, which is the one almost cxcIusiTely e]itplo}'ed. 
The water of this spring possesses the following 
properties. The temperature is about 160° Fahr., and 
it emits copious vapours; in odour it somewhat re- 
sembles quick lime, and the tasto is not unlike weak 
but highly saltwl chicken broth ; its density is 1006'6, 
and it contains in the 1000 parts, 8 parts of solid 
nuitter, and O'O parts of gas. The detail of the ana- 
lyeia b)- M, Freeenius will be seen in the Appendix. 

When the water is allowed to remain in contact 



m 



TBEATUENT OP GOUT. 



with the air, at ocoura in tlio IrnUu, a peUide forms 
<a the mrfiKx-, of a eumowhiit grCASy «]>poiintiioc, but, 
in reality, it ootisUta of carbonalo of Umo, wbich the 
eaoi^ of corltonio lusd has nnderod iosolulilu. and 
no ^prooablo nmount of otigaoio smttor ut prvMiit 
in it 

It will bo oridont from the coiuidfimtion of tho 
naturo of Witrabiideu waten, that tho offceta iinxlucod 
hy them upoti tbo coooomy an duo, in |)«rt to tho 
exhibition of water at n Kigli teraperatnre, in {tart to 
tho saiinc inattors coiilained in it, and more < 
to tho chloride of Hodiiun. Tlio lime salts, as tbo 
bonato oad sulpbato, probably poRKw some influonoe,^ 
M also tho &ee carbonio acid and tho nmoU aiuoont of 
iron, but thcee, aa well as the remaining ingrodioot 
play u very secondary part compared with that i 
by the common Bait. 

The physiological ofiecto tunally prodoccd by 
mit«rs when talcon in Hmall dosen are, fiomo iDcroaio 
of tlu- saliva and buccal mncuii, giriog riso to fmiueut 
deglutition and ocuteness of the ta»to; a feeling 
warmth in the epiga-itnum, accompanied with uructa- 
tioD of carbonio acid gas ; along with these symj 
tiiere is usually an increaae of appetite, and iiapr 
Btent in the digestive functionn. After tlie ab 
of tho waters into the Aystem, tho only ap[ 
effect is an augmentation of the urinaiy soeretioo. 
Tho bowels are usually not affected by the vatois 
except they are taken oold, wlien they somiMuiua 
produoc a slight action ; on tlic other band, if flio 




UUfERAL WATERS OF WIIIISIIADEN. 



476 



pslieiit drink them very hot, coostdpatiDD msy be 
induced. 

If the waters ho administered in larger doees, nil 
the above Bj'mptoms become more marked, and unless 
the skin and kidneys act very freely, slight diairbcea 
is apt to occur, with stools rich in the biliary con- 
stituouta uud otliiT oocTL-tiuiis from tbu iiitt^iiial tube. 

These lurgo dueci if continued for suvcrid wooks, 
gcoondly give rise to u dtiuiDUtion la tho weight of 
tho body, a&d this is inoro espmidly seen in the 
deorwao of nbdominHl fulncu ; cutaneous eruptions, 
Oipeoittlly acno, are often dt-veloped, and sliould the 
waters bu persevered in bi7ond this point, ^juiptoms 
indicating the saturatiou of the system with (h« saline 
matter uppcar, indicated by great avorsiou to tho 
wateni, eruelations, thirst, furred tongue, and a feeling 
of proetrutiou, pointing out tho propriety of discon- 
tinuing the treatment ; if pcr«vcred in, vomiting and 
diarrhuBu, oonge&liou of the organn of the chest and 
hfiod, and other very unpleufiiuit symptoms may arise. 
In still larger doKtt, the watons prove decidedly 
purgative. 

I>r. Braun, in liis work entitled Monographie dca 
Sanz itin^ralee do Wiesbaden, has given the reenlts 
of eomo experiments made for tho purpoEe of ascer- 
taining tho oSboti of tticeo waten on the urine, and 
tboflo appear to ^ow that a lai^ incn-an in tho 
elimination of nrio acid and urea nriKs firom their 
exhibition either in the form of bath «tr wbc-n taken 
intvmally. If these results, which will bo found in 



4» 



TEKATUENT OF OOOT. 



the Appondix, were confirmpd I)y further obwpvatioii, 
they would indwd gu fiu: to oxplnin Uk' value of the 
tiiermal trcatmcul [lursued nt Wic^flbtuliMi, 

Tbo action of the Wi<!jibadon waters in the form of 
batlu tuiTC boon invciftigntcd by Noubaoer and Dr. 
Genth. Ifoubaucr found tliat upon himself biUf an 
Iwur's bath inoreaMd tho amoaDt of vater, aUo the 
uva And urio acid, and, ta a slighter degree, the other 
aitn&ry constituents ; it also increaaed the free acidity 
of tho orbc ; but, in Dr. G«tith's ooaOi thfi eEEbct vat 
diQiDront, as tlic bathing diminished Uie urea, and 
only iDoroowd to a rcry slight degree the urio acid. 
Ncubsncr found tlmt drinking the watem inc 
tlic un>ii ; Dr, Grnt.Ii, on Uio other hand, noticed 
di'crra»c both in the iir«a and urio add. It mt 
tbereforv bo considered that at present notlung 
definite hiis b»'n mode out concerning tho phyao-- 
lo^iool effects of the Wiesbaden wuten. 

Tho Wioabadon watcrx have been strongly rcoom* 
mondod in gout, and there are ocriniu fonns of the 
diacoso in whicli tliey may be udvuitageously adiiuiaf>j 
tored ; they are more capeoially indicated for sabje 
in whom the circulation is nlug^sh and the Booretia 
dafioient, also in cases inwhioli tlioro is much stiffite 
of the joints from previous nttaeks. It Is not 
common for an actite attack of tho disorder to soil 
Tono after the waters have been taken for a shoK 
time, and when tliiit happens they must bo disoootaaued. 
^VhcIl there is much debility, tho Wiesbaden treat- 
mont should not bo attempted, and great oaro is 




I 



MINERAL WATERS OF WIESBAKEN. 



nOOHBOty with regard to tlio uec of tho haths if thoni 
bo tl^ Quptoms indicating dis04uc of the organs of 
the ohc«t, or of much injur>' uf the kidiic)-s. I have 
hod tlic opportunity of watehint; the kSv<As of the 
"Wiesbaden waters upon numcrou.'* gouty subject^ but 
cannot say that thoy have often been productive of 
much benefit, as they have not appeared to dimtnieh 
the frequency of the attnolm nor to cause them to 
become less severe; it most in fairness bo added, 
that patients seldom report to Wiesbaden from this 
country till their gout has become both chronic and 
intractable. 

Did tho waters possess the properties ascribed to 
them by Dr. Braun, they certainly should not bring 
on an acute accession, for the blood would bo at onoe 
rendered too pure for the occurrence of the gouty fit 
to bo possible. I believe the waters are more adapted 
to the treatment of chronic forma of rheumatism ; at 
the same time I have little doubt that their proper 
exhibition in many cases of true gout may be attended 
with adrantage. 

Dr. Bobertson informs me that, after seven ye&r^ 
experience at Wiesbaden, he has come to tho con- 
cIufiioQ that the Wiesbaden waters have no very 
specific action in true goat, but are more advantageous 
in chronic forms of rhoumatism ; lu gout they arc 
UKefiil if it be desirable to bring ou an attack, which 
they often do. Dr. R. also remarked that when batlis 
■nrere taken tho patients became much more quickly 
influenced, If the temperature was under that 



173 TREATME^T OF OOCT. 

of the body, but that most pationte took tbcm too 



wnnn. 



Miifral Springs of AiX'Vi'ChaptVf (RfimM Pni»»U}. 
— Thu watere of Aix-lo-OhapoJie iiro chartdcrwcd by 
tlieir peculiar odour, and many of the springs hare 
also a high temperature ; although apparontlj' differ- 
ing from tlie mineral waters vc have hitherto con- 
ndcred, more minutR examination -thows that tho 
diSbrence is by no means so marked aa might be at 
first anticipated. The principal spring is the Km- 
peror's (Kaiserquelle), the water of which is clear, 
smelling rtmngly of itiilphurctted hydrogen, tempera* 
turo 135° Fahr., and sixteen ounces contain about 
thirty-two gmins of salinii matter and twenty-ax 
cubic inches of gas. 

Tlio onalyna in the Appendix shows that the watv 
is snline and nikalino from chloride of eodiom and 
carbonate of soda, and that the odour i« duo to tiie 
presence of a minute quantity of sulphuretted hydn>- 
sou and a small amount of sulphide of sodium. 

Tho tlierapeutic effect of this water is similar, but 
less potent than that of Wiesbaden, in additaon to 
wbioh the sulphur it contains pr'>duccs a marked 
influence over the cutaneous function. It is, there- 
fore, indicated for gouty sahjeets in whom the skin 
is more than usually harsh and dry, and likewise in 
cnsQi where a general feebleness of habit exists 
combined with much rigidity of the joints; nt the 
same time it must be remembered that the eompo- 



UIKEKAL SPRIKOS OF BIDES- RAVEN'. 



m 



sitioD of the wat«r offers oothing pecoliarly fitted 
to oombat tlie gnatf diathesis, except that it coO' 
tains a small amount of alkali in the form of oaiioute 
of soda. 



I 



Minfntl Spriiii/t of Bat/nt-Baden, — As jct I hitrc 
had no experience of the value of these watem in the 
treatment of gout, but ns their powers in niodifyini; 
this malady have been recently tested by Dr. Ruef, 
and as Uthia has been found to be an importnot elo- 
ment in tb«ir composition, I cannot do better than 
introduce in this place a portion of a short article 
which has been recently inserted in one of the medical 
journals by Dr. Althaus. 

" A »-cry large quantity of Uthia was found in two of 
the tlicrmal springs of Baden-Baden, anmcly, the Fett- 
quelle and the Morquellc, of whioli llio former con- 
tains 0-231d grains of chloride of lithium in axteen 
onnce.^ of wntor, and tlio latter 2'3649 grains of it. 
In one hundred pounds nf tlio salt extracted from the 
Hurqucllo nine and three-quarter pounds nf lithia are 
contoini^d ; that u, a quantity of thiii subittance worth 
90/. sterling. Thb amount is not rquHlled by that 
contained in any other mineral npring which hat yei 
been examined. 

" In consequence of the anahsis of these Fpringl^ 
raado by Profi'^or Kuiison, they have, during the 
luft sca-'un, for the first time boon extcn.<tiv<'ly used in 
cases of gout and lithiasis ; and I am indebted to my 
friwd Dr. Euef, of Badcu-Baden, vho has treated a 



I 



180 TllEATMENT OK tfOUT. 

large numLi-r uf ceacs of that dc^icriplioa with thni), 
for tho folluwiug piirliuuluni regiirdlDg the result of 
their odiaiiiUtTutioii. 

" The physiological eHects observed aftt-r taking tho 
waters are as fvHows : — At first it promotes digeatioD, 
and » fc-oliug of wfU-beiiig is iuduccd ; but after they 
have bCBQ token for some time, and especially in lai]go 
doses, sickness, disposition to vomiting, and diarrhtea 
ensue, which in mort cases, however, grmluuUy dis- 
appear, but sometimes continue as long as tho water 
is drunk. A constant effect is an increased cliimna- 
tian of urine, the quantity of which is often doubled, 
or even trebled ; it becomes turbid after some time, 
and large quantities of a reddidi sediment uro depo- 
sited in it. In eome of the patients treated by Dr. 
Ruef, profuse perspiration came on after &om five to 
ten daj's, and continued as long as tho nittor was 
drunk ; and in the case of a lady who hod not freely 
perspired for years, this perspiration even ooDtinoed 
two montlis after the cure hod been finished. It 
therefore appears that tho water is a diuretio as well 
BB a diaphoretic. 

" Concerning its therapeutic action ; in almost all oasce 
the pain in the joints is increased at 6rst (espednlly 
in those patients who were in the end cured) to • 
rather high degree, but it never spread to healthy 
parts. Id joints which were perfectly ooDtnwted, 
crackling, dragging, and pulling were felt, as if the 
articulations were being torn asunder ; but after such 
an attack of pain, a sensation of cusinciia and decided 



4 




M1XF.RAL SPRINGS OF BADEN-BADEN. 



4St 



1 



improTemcut was felt, and tho mobility of the limb 
wna much incivascd. In one patient, a pbysicino from 
Epemay, a rcgnlar fit of gout came on during the use 
of the wator, under the oonltnuod uac i>f which tliis 
patient so rapidly improvMl, that he could walk about 
again after thrue days. 

" Gouty aifeotions of the joints, of the sheaths of 
the ncrvca and the muscles, if not of rery long »tnnd- 
ing, were cured after three or four wwks, mid liavo 
remained so up to the present moment. In jteriodically 
recurring hooducho on odd nde, whieb 18 often due to 
gont, the effect* irerc alao rcry bonefidal. A liidy who 
had been oontrocted for fourteen yean;, and who could 
Doitlter stand, nor walk, nor onrry n spoon to tho 
mouth, was by the use of this \mter so much improred 
that she wa9 able to walk u little, and to »Utni ood 
eat by herself, while no fonner medication had relieved 
her. Tlitt patient also Mitfen^ from d^-smenorrhten, 
the most pronuDent symjjtonw of which were ncvero 
abdominal pnin, oppression and ostluna, cold and 
pamlysiB of the left arm. Site had only taken tho 
litbia water for eight days when tlio eatamcnia ap- 
peared, and were unaecompnnied by any nspleoMat 
^nnptoms whatever ; nor did these latter reappear 
afterwank. In a male patient whose tinger-jointa 
were infiltrsted witli urate of soda, which was risible 
in white specks ihrnugli the skin, tl)e«o iniiUralious 
were remoTed, and the swelling diminished. 

" The mnde of adminutering tho water was as fol- 
lows : — For patients with whom brgo qaantitte« of 



Hi trkatuent of ooitt. 

water do not agree, fire fruas of tho carbonate of 
lithin WL-TA Bd(l«l to a bottle of the water of Murqaellr, 
which contains fire gratDs of chloride of Uihia ; and 
tho water was then impregnated with curbooio acid, 
in order to render the Mthoaute more cotnUe. Of 
thia Witter a tumblerful was drunk thnw timoe a day ; 
and if an locrease uf tho dodo appuared neooesary, two 
or tliroo grains of Ihv carbonate were added to ererj 
ffiam. If patients nrc uhlo to keep moch water on 
their stomach, thoy may take nx or eight tumbU'rafd 
of tl>e MuniiK-II(<, without any artiiwia] addition of 
carbotLnto of littiia, Batlis witlt wat«rof the rbsio 
nprtng weio oln giron ; and tho Administimtioa uf the 
Spas of Badon-Baden ara now ooctipied in preparing 
a Bother-lyc from th« water of tlio Mun]Uoll<>, in ordtr 
to gain so much of the salt that it may nt^-xt year ba 
addod to tho baths. Of all the antarthritic remediu 
offered by tho Rprings of Baden<Baden, nuno luro 
proved so boooftoial as tltis litliia Kpring. J >r. Rucf Iim^ 
in some coace, at the same time employed tho Ituastan 
vapour-liatlis, prepared from the steam of tlK^ liottcot 
spritif; of tlio place, which has a t«mi»ermturo of 
156" F."— J/rt/iVwi J.«*« attd Qazrlt^. 



Water* of CarUbad {Bohemia). — A referenoe to the 
analysis in Appendix will show that sulphate of »uda 
is tlio principal ingredient of Carlsbad wators, hot 
carbonate of soda and ehloridc of sodium are impor- 
tant constituents, in addition to which tho high tem- 
pemturo adds powerfully to their tlierapcutic influonee. 




1I1SF.R.U, WATERS OP CARLSBAD. 



48S 



I 



In tits majonty of pationtu a pnipitive action is in- 
duocd by the exhibition of tlieso wutcn;, usuaUy 
followed I>y copious ditircsis, mid «>idu oxcitcniont of 
tho Tiificulur it^'stom. Owing to tlic prcscuco of tbo 
carbontito of «oda> Uicsc vrutcrs possLtM tlio power of 
ivii<ieri[ig tho fluids aiorv alkaline, and thus in some 
nt^pecti, reacmblo those of Vidiy. 

Tho WRten of Carlsbad are employed with most 
advantage ia gout connected with fuluess of habit, 
combined n'lth derangement of the liver and deficient 
McrctionH from the alimentary canal ; in oases, th«ie> 
fore, iu which the di»fu5e U mora ospedally due to 
the exceasiro fonnatiun of uric acid : in weak habits, 
or when the kidneys aro seriously implicated, they 
should not be leaortcd to, as they may llieii bo ppo- 
duetivo of Borioua mi»chiof, from the puwcrfid difiturh- 
■ncc they cawo in the whole syHleiii. 

Id the same eatcgory of mineral ^ringn may be 
mentioned those of Eiseingen, Harienhad, llomburgh. 
Ems, Soden, and Chc-ltenham : all of tliem contain a 
oonaidereblo amount of tudiuu malt«T suitable to par- 
ticular forms of gout, and some, particularly Emu, aro 
likewise alkaline from the prcHince of a httle carbo* 
DAtoof soda. 

The .icoond clas of mineral waters embrooca Ihou 
which owe tLeir thenip«nitic powers more especially 
to tho inllueaoe of tlie water itklf, onm in«roMed 
by its high tcmporatnre. Tho more imjmriant 
aro tlMMO of TcpLitz, Wildbod, Uuxton, Oastcin, 

t iS 



Hi 



TBSATUEST OF OOOT. 



and Batli. The anftlysos of the first three vatcn wiU 
be seen in the Appendix, and Toay be taken fts ^'pcw of 
the whole class. The mineral constituents nrc iueig- 
nificani, and con add but little to the thernpeiitiu pro- 
perties of the water itadf ; as regards tbo Buxton 
wateni, an atttmpt has been made to refer Ihcir acdoB 
to the larf^e amount of contained nitrogen, but, to ny 
the least, the explanation is veiy problematical. Then 
waters are more especially used in the form of the 
bath, or douche, but many of them are adraDtageousl' 
smploycd iu< iut4.'nuU ittmLilios. 

A very large (Htrtioii of the ri«itors at TepliS 
labour under mmc form of gout, and it i« a^sc-rtMl 
that much beuefit ut dorivt-d from the administratioD 
of the waters. 

The Tepltti: ^rings aro most suitable ia 
attended with debility, end tho baths are tspecaaUy 
indioated when the stomacli is unable to bear a iargt 
quantity of liquid ; long immersion in a water of lor 
spocifio gravity, and one containing but iittlo saUA 
matter dissolved in it, is favourable to eudosDumX luid 
hence considerable ah§orptian ensues. As tlio solid 
ingredients consist chiefly of carbonuteo of soda and 
lime, with traces of iron, a slight increa-w of alka- 
liuity is givL-u to the animal fluids, us likeu-ise some 
stimulant action to tho secreting functions — efimtt 
whic^ equally result, whether these wntiTs are ad- 
mintslorcd in tlio form of the hatb, or taken intcmally. 

The remarks made on the Tcplitz waters apply to 
many others, mora especially to those of Wildbud. 



4 
I 

ati oB I 

4 




EUrLOYHZirT OF UIXEBAL VATKRS. 



4U 



Gastein. Bath, and Boxtoo, wbioh contain but a 
triditt^ amount of mmeral taf^rodieate. With regard 
to the efficacy of Dath waters, Uoberdco mada the 
remark, that be bad oat b<>en able to hoc any good 
remit frt>ni Uieir oxtomal use, cither vhen gout ira* 
prcwnt or in th« inUirrala ; on the contrary, he 
thought they appeared rather to increase the weak- 
ness of the limbs. 

In certain forms of pout, cspooially afU?r s courses 
at any other spring, the ferrugbous waters are of con- 
siderable value, and of theso the mont important are 
Spa, Schn-albnch, Pynnont, on the Contincot, and in 
this country, Tunbridgc Wellis. 

From what has been now advanced conoenung 
the nature and action of the sororal mineral springs 
wliich have ncciiurt'd reputation in the treatment of 
the different forms of gout, it is endcnt that much 
caution is necessary to prevent tho occurmtoe of 
miMhievouM consoqucncoA, and considerablo judgmeot 
dctnaitdod to ensure success. 

Tho ndeii I now subjoin will safely guide tho prao- 
titioner either in advi-sing or in proscribing tho exhi< 
Intion of mineral waters in gouty casca. 

Thoy should be altogetlier prohiI>it<rd when there 
b oonsiderablo structural disease in any important 
organ, evpccially in tho heart or kidneys ; and even 
when the orf^nic mischief is slight, tho gn'ah«t 
caution in ueceftMir)' in their use 

Thoy sliould b« avoided when on aeuto attack is 
either present or thraateniitg. 



48« 



TnEATMKKT OF GOUT. 



4 



Tlio vrntcn Klinuld be selected n^cnrding to 
&ntur« of lh« cn»e. Whon tho pntient is robost, an2 
of full liiibit, the alkdliiio salitic springs; when tor- ^J 
pidit^ of tlto b<>wd.t prodouuDatvi), the pur^tive ^^ 
watera ; when there is a want of vascular action^ the 
saliuo vat«ni ; whoa the sVia is inactive, the imlphur 
apringis ; lastly, when dcbilitj* prevails, ibi-n the more 
simple thermal waters should be chosen. 

Id all oases the use of the waters should bo cma- 
tioasly commencfd with, and caro takm not to 
oppnes the stomach by gi^'iiig too itiiif^h liqtiid, nor 
to induce debility or any other iiijunuu« offuctit bj 
allowing a too long sojourn in the bath. 

In condufiion I may add, that wo should not 
expect too much from the exhibition of mincnil 
watt^Tc, as their influence, erco when most Bdvaa- 
tagcoufl, endures hut for a i«hort time, wln'reas tlip 
causes of Uie disease arc, in many cases, in constant 
operation. 





(<» 


,V 


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t.Y 


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! Xi^*^ 



l^^U^ .■-' '^ 







CHAPTER Xl\'. 



luMBUB lovt* or Ooin:—piiunn«xRT ommtitiom— nirri- 
CObTrKi or HIE HTuriaiTiaii or ritauiDuft rouiii C'l oout — 

NOM e» UCIKTllXiVa TUa Tflll* XATDU OT IlimDIi|.t AfU 

AMoauAu* rjt«a— KKTEociDUT on unmitio aoit— iHri.1- 
oinao IB* miiuon, nxjiir. ah- uvis — mitt fmcTiia ma 
lno«m»i onej-Ki — TMi aitnT— vnK mii-iiLitutu uxaA**— 

CttlllNT Oium— TBB )BT«— init E«R~tn> till— TDK XlKTUUt 

i»i NUKCua Jtnuo— tAWMKn of tjta Mrmnit mbm 

Of tUUVUM MUT. 

TTk now approBch a subject beset with dilBcultiee, 
and ooa which requires the inoot careful exercise of tho 
judgment in order to arrive at results eatisfactory to 
the pathologitit That there are irregular formi; of 
gout must be couceded by all wlio have turned their 
attention to the 8tudy of Uiis diaeate, and daily expe- 
Hcnoe contirmti the cvnooesion. It is not uncomnuni 
to find a patient with Ayinptomii which may be pro- 
perly dossed under this head, long before tlic advent 
of a fit of goutr and although euch symptoms may 
disappear on the occurrence of the paroxysm, yet they 
occasionally continue, in a mitigated form, daring the 
progress of the articular inflammation, and are often 
inraeDt during the intervals; now and then, indcod, 
they occur in subjects who have never expcricnoed 
a true fit, but who probably eitlier inherit gout, or 



isa 



niBDuuB wnn. 



at IcaBt have bccD mocli exposed to its predisponngj 
oauseo. 

Wliim at any time vre can dcmonstrato tlmt tito 
symptumfi depend upon tlie eamo diathesis as Ivada 
to the inflammation of tho jointR, wc ore oprtninljr 
justified in oonflidnruig tbon na irrcgalar mftniri«- 
tutiunti of pout. Ttio difficulties in distinguitjliingj 
tlic tnio nature of sucb snomaloM Bpnptoms aro' 
many ; fur wo must rmneinber tlmt tlicM patients muy 
be alToctod with iMtli fuiKtioiml and organic i 
not Rcocanrily gouty ; for oxiinipl«, phntriny may nooor ' 
from exposure to cold, broncliitts from a flioiilar cauao, 
and although tlio couivo of rodi diaraaM may to aomo 
oxt«nt bo inflaonocd ]>y the condition of the sjttom, 
yot such compli<!atians can scareoly bo dMiointnatcd 
gout)' : thnt tliio luii boon commonly done tUerc it i 
little doubt, and thus have arisen tlie numercHifi fonna j 
of irregtilttr gi>ut d«acribad bymanyof theoldorwrilon 
in thin couiiti-)- and on the Continvnt. 

Many of the more powerful predisposuig cauaea' 
of gout t«i>d to produco other diseoMS, but when 
these Inttor occur, they are not neoos^ly of a 
gouty oharnctvr ; »ueli cnuHca, for example, will nut 
unfroqucntly loud to onrdinc diMtoaos, a« dironic ral- 
vubir iUt«rutionii>, ntlieruuui, and hypertrophy, and I 
liaro n.iGiT(uiiii-d. by putit-murtom examination, Uiat 
even when Aticli cliniiges occur in subjeeta who have 
long been aiflleted with gout; tboy have not the aamvl 
con)po»ilioD or etructuro aa those OMontially connected 
with this diaooso; oxamplos illustrating tlits point wilt 



UlFFlCfLTlES IS TH£ ISVESTiCATIOX. 



US 



be found in the Chapters oo paUiologicnl anntomy. 
The long-continued existence of chronic gwxit often 
leads to a depraved conditioo of the ^ncral nutrition 
of the body, and the slow production of mtiny organic 
diseases, a circumstance which must not ho lost sight 
of ill the iuqaiiy. 

From a curcfnl cxaminntion of many recorded oases 
of anomalous gout. I um of opinion, that by far the 
majority have uo real claim to be M> oonsidflred ; some 
are ill DO vay related to the ditoote, and utliers 
only w far OS tlicy occur in gouty oouditiona of tbo 
habit. 

There can be no question that th« eamo disposition 
which ordinarily leads to the d(>v(>lopmcDt of regular 
gout, may produce symptoms ultogothvr apart from 
tlic jointly, but still ciHentially of a gouty character : 
vi\! sliuU uow direct our attention to the iuvcstigation 
of such affeotioDS romemhcHng th»t it isof the highest 
importnuce to the advaucomt-nt of mtxb'cul seaenoe, 
that we ithoutd not use tliu latitu<lc wliich the term 
irrc^lor gout affords us ai4 ii douk for our ignorance of 
the iiatnre of any diacaw, but ap]>ly the name only to 
such instances oa we can dciirly dctnoustrute to depend 
directly on a gouty state of the sj-rtera. 

Insular fomu of gout have n-oeivcd various namee. 
OS anomaioM goat, non-articaiar {font; and by tho 
Frcndi oertoin ^-arieties have been named gouUe 
iarrif, ffouite m^w, podttgnt tarwUi; at timet) the 
tenn mutpiactd ijont is employed ; hut »»mo writers 
include all these different affections under the Lead of 



w 



taOKOULAB OODT. 



dKan of ttte ijntnD duradarindlqr^'nif^ t'"'*^ 

ITpna Dxatnining a eon BOspootcd to be ono at 
lingular i^ut, wo siiould tnvmtignto Uio huitory, in 
order to find if there bit any h«rv<]itary produposition 
to the duc-iLsc, nnd to what dcgrvL- Uiu oxbrtc; nnd nlAO 
to (iiacoTM- if tlie predisposing causes of goat have 
boCD opcrfttlrc. Tlio ugc and tex of tlio piitii-iit eihoiild 
likoiri«c havu due weight iti tho inquin*. 

It should ho ascertained nhi-thur thcru has bccD 
nny joint nHoction, and, if eo, tlic pooulinntios wliioh 
it oxhibitcd ; it is niso iiDporUiot to aecurlAiii if the 
^'mptoDis, supposed to dupond on the gouty state of 
fakbit, are infliuntcod by causoe kiiown to iiif<<c1, in a 
suirkod degree, tnto gout. 

If there bo muob doubt im to thv nature of tlic cose, 
it may ocoamonally bo dcdmUo to eumino Uii- oon- 
dition of tlio blood, by which means a duo may bo 
obtainod, for, m wo hftre proved that gout is invari- 
ably nttcniU'd witli impure blood from tlio pnsflonoe i 
urio acid, it follows that when, in anoDudaiu 
the blood is not bo altered, the n'mptoms conii 
depend on a gouty diathesis ; if, on tlie contrary, tlM 
blood exhibit »ich impurity, it is a Buttor »f higli 
probnbility that the phcnomciift are M> conoecti-d. 
say, probnbiLity rothor than oortainty, inasmuch as 
uric oviil ocoiu^ionolly exists in tho blood without 
pitiductioii of any ohoroctenstio sj-mptonw. 

In order to rediuw tlio phenomena of anomalous 
gout to a Bcicntifio precision worthy of tho pr 



DimCULTIES IN THE INVESTIOATIOS. 



«1 



ng6, the above oonatcleratioiia must not bo lost dght 
of; for if the fects advanced in the precedinp chapters 
bo COTTfCt — and that they aro so satisfactory evi- 
dence hus boon adduced — I huvo no hesitation in 
affimiiDg that what has now bi-oii stat^^^I with regard 
to the blood in cases of irregular gout must bu so 
also. 

There is generally some little dillicuhy in theAc 
eases in determining the pn'iteuce of uric iicid in the 
blood, a« venesection is seldom nWolutoly requimtc, 
id tliere \9 a miturul repugnance to itjt perftuniiinco, 
Jtlurugh but a single ouuoc l>e n-quired. In fuch 
in»tiuic(^ I have oocamonally had rccoursie to • blister, 
tlie application of which ts sometiincs advLsabIc as a 
tJterapcutie agent, and can never be productive of 
injury ; it Dtust be confessed, however, that the exa* 
minntion of tlie serum from n blister is nat so satisfac- 
tory aa of that from blood, although, when positive 
evidence of the presence of uric acid is afTorded by it, 
the results are equally conclusive. 

In treating of irregolar gout I shall first speak of 
that form denominated rotrocedent or metastatic, and 
then proceed to describe the other varieties acconl- 
ing as they affect different organs or tissues of tho 
body. 



Xetrocfiieiit Ooui. — Qowt is nam«l rctrocedent 
when a sudden disappcuranoc of tlie articular aJJectioo 
LI followed by serious misdiiof in some tnt<.<nial visciis, 
as if a Dtetastusis or ehange of positigu had taken 



«M 



iBRFAuuB cotrr. 



place : the organs tuunlly ntUuiked an tlto itottuuh. 
Iho huart, or bmiD. That rkIi a motastani of 
gouty inflammntioD oocruiionally oocnra is andoubted, 
liut it id iM> Uw traa that in tbo myonty of tlw 
recorded instaDoes considemUa miadiMf had pre- 
vionaly existed in aomfl important organ, vliicb proved 
tbe immediate oauso of tho so-called metae^atic action. 
To scparati^ tlio true from ttjmrious gshcr in a task of 
mucb difficult)'. 

WbcD th<> tfomHek is attacked, the flymptonu 
indicating the transference of gout aio an intoiiHc 
feeling of oppreasion end ansiet)*, o^d aocompanicd 
with spasm, pain, and vomiting. Cm)to relatctt the 
ease of a soldier who caused the gouty inflnmnifttiaa 
to tiubndc by the application of spirits of oani|ib<ir to 
the joints, and was immediately aeixei with coM 
sireats, and vomiting of a green-coloured bOe. Sydim- 
bnm appuuro to have miflicrcd from similar symptoms 
on tlio retroociwioD of goiit from hi« limbs. 

&T C. Scudainoro rolfttw two com* of this fotm 
of diaonso, of which the following are short ab- 
stnwto: — 

Oaao 1. — A. eorpulpnt man, nfod 47, had mffervd 
from gout for twenty-live yean, and hod been trratL-d 
with large doace of the e«u medidnalc, which much 
doproMcd him ; and Imd aUo left off wine, in vrliich he 
fimnerly indulged. llaWng one day bc«n exptMc-d to 
oold and damp, when tiufforing from gouty Byntptunu 
iu his foot, although ho felt no tnoonvonionoc nt tho 
time, yot on the following night he was suddenly 



BETKOCEDENT CODT. 



in 



scutod with excruciating pain in the stnmach, and such 
an oppression from flatus that he thought hi^ Btomaoh 
would actually bunt : hot fomentatinnn, ether, opium, 
and bra ttdy-und- water rolic-vod tho alarming symptom*, 
wliii'h wort- f<iUuwe<l by a tu^vurv puiuxyem of goat in 
the kui-ffi and fcut. 

On auolhor occasion this gcnttcmui, from cxporare 
to cold, had a ri-turu of Jtyniptoms, tliough of a dif- 
fiirent churiiotiT; ii Itind of lorpar auuc OTOr him, 
the ])iil»e waa slow and languid, tho ^kin ccild, ft-alurrs 
oollaii^'d, and breathing laboured, nnd botli speaking 
and deglutition were difficult ; stimulaute were again 
suocessful in giving relief. 

Case 2. — ^A gL>ntlemim, aged 52, bad bin firat attack 
of gout when 31 yeare old, iiifecting one of his feet. 
^VTien still suffering from goutj' s)-niptonis, aiid after 
luviiig eaten heartily, and drunk madeira-and-water, 
be was oxpiHwd to tho eold air. Suddenly there 
occurred uu alanning oppression of breathing, cold 
perspiration, and u seUMitiou of burning rieing up 
from the bowels, but no pain ; also iiaasca, nnd a feel- 
ing of HioluDgi so as to caujM? an upprchonsion of fata] 
syncopo; there wvs aUo palpitatJoti of tho heart. 
AAcr drinking warm water, so as to produce vomiting, 
a hrgo amount of acid matter wax ejected from the 
•lomacb, with touucdiale relief. At the time these 
symptoms were urgent the foot became easy, but on 
their abatement there was a retum of acut« gout in 
that part. This patient had a subsequent attack of 
R-trocvdent gout of a nmilar choraclcr. 



<M IRREOVLAR OODT. 

The exact pathology of ratrooodoot gout, vlton tt 
attack* tho stomach, ix difficult U* dutcrmino. Is it 
ever inSummEitory f or dooB it simply coiudst in vio* 
lent it])a$m of the muscular coats of the organ ? The 
cases wliifli have hitherto bocii recorded do not safBoo 
to settle the point, but the remedies which rcUovo 
would appear to show that it ib functioniO. Tbc 
application of cold is jicrhupM the most commcm 
cuum of rctrocti^ssion of gout to the Ktomacb, eepo- 
cuiUy when accompamcd with a heavy or indigestible 
moid. 

Dr. Homo relates the case of a gentleman who ex- 
posed himself to wet and cold when fEuffcring from 
slight iiiflammntiou in his feet, aiid the same after- 
noon enteritis followed, which in twelve hours proriNl 
fatal. 

This liwt cojw, as well as many others on record, 
can scarcely he considen-d as un example of retro- 
cedent gout, for exposure to wot and cold will gire 
rise to inflammation of iutcmal organs, indepL-ndent of 
the gouty diathesis, and it us extremoly probahlo that 
when a patient is suffcnug from articniur gout, the 
ByKtem is rendered very sueccptiblo to the iuBuenoe of 
those causes, and consequently a less amount of expo* 
sure may produco M-rious mia-liief. It is difficult to 
conceive thtit if the intt-nml iufliimmution is dmply 
of a gouty chamctcr, it would lead to serious conse* 
queuccii, M^eiiig that when gout attacks tlic joints, the 
injur)- caused is by no means so greet as that induced 
by other fomu of inflammatJou. 




nETROrEOEXT OODT. 



4» 



1 4MUiitot ny that I have ever witnoescd a CON to 
whidi T diould feci inclined to npply the lUunc of 
retmcodont guiit of the stomitch, ttltbough I bavc often 
seen symptoms amo lii gouty putiontt which might 
probably be so dc«igiintcd by many physicinna. Tho 
inatanoea which have come under my ubHorrntiou hnra 
always been explainable by other means, and, 113 Dr. 
Watson justly remarks, the so-called gout in the 
stomach has sometimes turned out to be pork in the 
btomuch. 

Without (lonyin;; tho potability of acut« gouty 
inflaiDiuiitioii attacking this important or}riin, I am 
inclinod, until further evidence has been adducod, to 
doitbt its occurrL-ucf, iiiid to ruf^rd the ^i>-callod 
iustonocc as uilhi-r diptiiduiit on ordimtry g;t.«tritiR 
ocoumDg in goaty habits, or as forms of ucuto dys- 
pepsia, to whieh suoh subjects are peculiarly liable, 
depending on sudden lues of power in tho etumach, 
accompanied by spasm itud flutut. Shocks to the 
nervous fytAcm, ua powerful mental cuotion ooourring 
shortly after mcobs ftr« often productive of gastrio 
c^ptoms, and it may be that the sudden rqjvession 
of articular inflaiuniation U capable of influoncuig the 
ncrrona sjstem in a similar manner. Hunter was 
inclined to regard the effect of gout on tho stomach 
and bowcl.4 as altogether diasiniilar to that apoo tho 
exti«miti(« ; but Sir C. Scudamore thought tliut tho 
established opinion of an occasional transfcrenvo of 
inflammatory' action from extoruul to internal parts, 
in cases of gout, hod been clearly made out, and that 



p 


DSIH 


1 


IH innEGULAS OOUT, ^H 



it WW importuit in pneticc as well as 
doctnne> 

Whon the kfari is eeieed with 
thvni ill oflually a feeling of coiutriotioD abo^ 
ofaoet, riolont pitlpitatiou, inlcnso aaxic^, difljjj 
braUkiuit, ac«(>iii|HiiLi»d by a reiy smalt tH 
puUo, nud other siinw of synoope. A wpll<m8 
in»t»noo of tliis funn of rctnwedeot gv'ut is relate 
Dr. Alexander in a gctitlomon, wliD, when sufl 
(Wim « wvcre attack of gout, rery imprudfmtly ap] 
8D<iw tu tb<! painftil foot, which producml 
pT-»l relief fnini tbe pain, but was aoon fuUowt 
Di'iiwttiiiD of burning and confltrictioD at tlie 
part of bi» ehett^ as if a rrnl-hot iron wire hntl 
plaeod round hinit and that it was being 
tighter And tighter; nfU^r this bo could man 
nothing ; ho woa fcand nttiiig in hia rbair, 
ti«unl florid oompt«xion cbnnged to n dcath-liko ; 
re«pinitiou oxoeodingty slow and uiatchiiig, 
and uhnoit iinpoTecptibh>. Ho wu restored 
aid of Ktimulant* and eountor-irrttanta. 
•vident tliJit in tbb itutancB tlip oold appU 
pivtduocd puwi'rfiil spasm of tho heart, Ic 
extrmety dcft'diro actioa. 

Whetlicr tho heart is cror attacked with gi 
infliunmntioD in still a natter of doubt, for (bi> f vid 
in support nf its oceurronoo is by no means cuiiclui 
That it is fn><iacntly spa.-<niodicul1y affected is ocrl 
and probably, in most of tho oases of retrocedont | 
wbidi bavo proved fotul, somo oanlioo mis 



loodui 



B^TBlOCEDE^T GOtt. 



m 



N 



ralmlar disease, dilatntton, or fiitty degeaerntion, had 
existed previously. 

When retrocedont gout ntta«k« the htad, apoplexy 
is conunonly induced, but maninool ^inptonu occa- 
HionftUy ftri*e. When the apopk-xy hew tcnniimtvd 
fatally, wroun cfTation has been found in the brnin ; 
swsh occunmce has usually arisen from the appli- 
cation of cold ti) a ^ubi' limh, m by plunp^inf; it into 
cold water. That gouty inflammntion should impli- 
cato the fibrous mcmbmnes of the brain, as the dura 
mator, might bo expected, but it neems probable that 
in many of the ca«ics in which apoplexy has Kuper- 
reood, the bruin wna proTinusly in a state of ramol- 
lifnnimt. or othorviKe di.'U'nsed. T believe no demon- 
stnttion ha.* ever been affonled of the pre«enoe of trno 
gouty dejWMla in thcw .Htnicturw. 

Dr. Copland rokto* nn in.«tanco which came under 
his notice, of a medical man who experienced nmp- 
toms of gout in several orgna* within the qpaice of a 
few houra; be had had an. imperfect attack in tho 
foot, and on its forsaking this ntuation, tlie boweU 
beosmo affected with violent colic, then the diaphragm 
•Bd lungx, causing the mo^t urgent dvspnoja, and 
lastly tho head wa« implicated in a .tlight decree; 
aftar thin the disease again appeared in one fbot, and 
subsequently in the other. 

Having given a otight sketch of those fcaddm, 
severe, and ob«curo wttocks to which gouty patient* 
■n ooeuioDally sahjoct, and to which tlio term retro- 
ccdent goat has been applied, I shaU now ondearonr 



IBS 



lUREOtJUB GOCT. 



to liiy bi>forc the reader some aoconnt of the discaso 
wbi'ii it implicates organs and structures other than 
those of the joiuta, or when it assomes the character 
of ab-nrticular gout. 



Gowii/ affeelion* refivable to llx Digestive Organt. — 
SjiuptoinH mainly referable to the digestive OfgODS 
havo already been described as being frequently pre- 
monitoi-v' of an attack of f^out, but it is uot unconmion 
to tind severe and piotracted dyiipepsia in patients 
who have never suffered irom a fit, but who cither 
inherit the disease very strongly, or who have sown 
the seeds of it by their mode of living ; in such caws 
tlie derangement of tlie digestive organs is donbtloM 
often dependent on an impure state of the blood, 
arising from the presence of urate of soda. Xt is often 
a matter of considerable difRoulty to make a correct 
diagnosis in these instances, but at times this difficolty 
is at once removed by the sudden supervention of b 
true iit of articular gout, and the equally rapid dis- 
appearance of the gastric disturbance. Such relief, 
however, is not always experienced, and patients may 
suffer for months and even years without the nature 
of thoir ailment being discovered, and this occurs 
more especially in persons who have led a very tem- 
perate life, but who are strongly predisposed to the 
disease : slight threatenings, however, of tho toe 
oiEecUon arc sometimcB, on enquirj', admittod to have 
bdcu felt, stifficieut to render the pressure of the boot 
nnoomfortabte. 




AFFECTING TUE mOESTITE ORGANS. 



BtBcIos the Bymptoms already described as premoni- 
toiy of a fit, other gastric phojiomena are occa^onalljr 
mot with, as gastrodynia, pyrosis, and entorodynia, 

A gout}' state of habit is often acoompanicd by 
coiiftipation, but sometimes diorrhoa ensues, and I 
have known aeveral individuals who iippcarcd to 
escape fits of articular gout hy the froquoncy of such 
eraouatioii from the bowcbi. 

The gastric disturbance vhicli preocdoa aeuto gout 
usually becomes iucretLsed in the chronto form of the 
disease; to such aii extent indeed, that the patient 
may be tormented iu the intervals of freedom from 
the joint affection, and unable to bear tlio olightest 
irregularity of diet ; this form of dysipepsia probably 
depeods on the augmented impurity of the blood 
arisiiig from the impaired state of Uio kidneys ; it is 
likewise a prominent feature in disorderx directly con- 
nected with ft granular state of these organs. 

I have met with one inMance in which the ceso* 
phagus won dl'ttinctly affected, so at t^ cause the 
greatest difficulty in swallowing, which s\'mptom was 
at once relieved by the occurrence of articular gout : 
coses are related in which Uie rectum has been con- 
stricted from the same cause ; and it should bo men- 
tioucsl that hemorrhoids frequently occur in gouty 
patients, and arc duo to tho congested state of the 
portal itystem. 

Tho folluiving examples are iUustratiTO of this 
fotm of gout, and are selected from among uumerouB 
Omilw COEM which have cume under my care : — 

s ■ I 



eoo 



IBREOtTLAS OODT. 



Ca« I. — A geaUeman, aged C4, whose gen 
health had usually been good, came tuider my care 
with tho following t^ptoms. For the last twa yean 
be had suffered tnm pyrooa snd attacks of Tiolcnt 
rctchinfr, but u-ith little Tomiting, uccnsionany how- 
ever he had noticed a (itn-»k of Llood. Ho bad loet 
flesh but was not vmscintod. The sickirass occumd 
diicSy in the tooming, and about two or three tiinaa 
in the furtuight lie vrm troubled with frecjuent a&d 
twrere eramp. Upon enquiry, I found that 
patient bad fur more than twenty )«an been tnibj 
to periodic attncks of gunt, gonorally in tho siiring 
tho year, and afl(x:ting tho great Iocs and knees ; bnt 
during tho time tho dyspeptic symptoms had boon 
present, scarcely any ^mptoms of articular gout had 
been mnnifestcd, or merely twingee in odo of tho tocv. 
Thinking it probable tliat the stomach ofEbotioa was 
closely connected with a gontj state of the sjstem, I 
prt?scribed with that object, and had very soon the 
eattsfacdon of finding tho disease rapidly givo way, 
and the patient in a little limo completely restored ta 
health. 



ana 



Caps 2. — A gentleman, nboat 40 yeore of age, who 
had for nomo time lived freely, was suddenly attttckvd 
with violent pain in the stomach, accompanied witli 
intense depression of spirits ; after a few djaj-s tiuao 
sj-mptoms wore suddenly rclicrod by tho oocunenoe, 
during tho night, of a sharp fit of atiioular goot 
ftffuctiug firat one then the other groat toe. This 



I 




JLITBCTISG THE mOESTIVB 0BGAS8. 



6U1 



tbo first timo ho cxpcrioaoed any altedc of tlie 



Cask 3. — A gcntlcmnn, lOi yean of ago, of !<dmo> 
wliftt spun) Iiiibit, inlicriting gout from his pntumol 
gmutlfathur, first experienced some pain in tho great 
toea nljout ten years aince ; three or four years aftor- 
Wll^, had au nffuution of tho right shoulder, which 
patscd off wiUiout treatment. About a. year and half 
(sinoc Huffored from a very severe attack of gaMrulgia, 
B^^ueatly eausud by mental auxioty ; tliLs was 
■ooompatued with some jaundice, hut not followed by 
any joint affection. About a fortnight ago he expe* 
rienood a second attack of go.<tralgtn, very acute ; this 
i^uddenly eiML«cd on the occurrence of sliarp inSamma- 
tion of tho lefl kooo, whiohis now painful and eauaog 
liim to walk lomo. 



Cask 4. — A gentioman, about 6ft yours of ago, 
who had hud alight attacks of gout for lifti^on yenr% 
oxpcrionocd tho following c>'mptoms. During tho 
time that he was KttfTering from the discuiw in one 
foot, ho suddenly fvlt extreme pain in tho epigastrium, 
aeoompaniod with vomiting ; tho pain in tho foot 
suddenly loft him, and romainod away till the gastrio 
distorbanoo had become relieved, it tlioii rotumed in 
Bomedegreo. 

Qotit affectiifg thti lUtiri. — One of the moro ooramon 
»ymptoni9 produced by a gouty state of the system Is 



' 11 muy be mreonj* Hunwa ry mo im] 
tbu blood, and I have notes of man 
no organic nuscbiDf (;ould bo <liHcovi'i 
not any sigas of indigoetion, luid in i 
tonts ccit^ed on tbc oocurreno! of goi 
but in many gouty putionbt in w)io 
proniincDt niid constant, by]]L'rtrop 
dtsoaoo cxisti< sufBdcat to account f 
It has been thought that tho structu 
oro sometimes the scat of gouty in 
great probability is supposed tu b( 
idea, from their being so constantly l 
rhcumatifm; that such may occosi 
do not deny, bat doubt if it is c 
altogether on error to consider colcoi 
proof of gouty inBomination, for I lu 
fonncr chapter that even in gouty sul 
concretions of urat« of soda lu all 
depnnts upon tlie aorta arc of a 
ehoractor, consisting oitlier of phosphal 
of limo or of cholcistcrine and fatt 
Stoker hjis obsen-od, that when death 




AFFECTISf. THK HEART ANB LUNGg. 



MS 



or «t least an irritabtc cnndidon of the uorla, is also 
occuioaaUjr produced lij' gout, and In some instances 
has caused a suspicion of the existonoe of aneurism. 



Sfipinitory organ*. — Cough and an asttmiatio con- 
dition of breathing are frequently produced by a gouty 
Btatc of s)-steni. A gouty cough a rwoguiaed by all 
practitioners, and often precedes and aooomptnies the 
rvpular forms of gout ; oocasJoually dyspnoea of a very 
severe chnractor, and to Huoh an extent lu to cnuM 
alarm, is connected with tho presence of latent gout. 
A patient was once under my care, having, it it true, 
somo slight emph\'Bcma, but suffering from great 
dyspnojB, so as to be uuablo to lie down, and was also 
much distressed by a hard dry cough ; the usual 
treatment, by dry cupping, counter-irritation, and 
ctpoctorants, was adopted, but with little or DO 
relief; after a few days, the chert symptom.* suddenly 
ranished and gout ucourred, first in tho ball of tlic 
left great toe, and afterwards in the knoc. Muy 
cases of a similar nature have come under my obwr- 
vstion, wid others are on record, all of which eUwriy 
point out that the respiratory urguns arc SOBlottniM 
affected by gout. 

Tho plemw may bo occaaonnlly implicat^-d, and a 
spMUS of dry pleurisy produced; the diaphnigin may 
bo attacked, and violent spasmodic cough induc<.'<l; 
ostlinia has also hcon noticed to be common in gouty 
Aunilics, and is probably do<> to the presencu of an 
impure stato of tho blood. 




m IBRBOOLAIL tiOUT. 

I csuDot \uilf tUiukiiig, fts tlie kmuU of much oxp^ 
mnoe, that iu ttlmost all tbo cases in which the respiro* 
toiy orgwu are thus afElMted« tliero is likewise present 
sense ^ttruoturol miMliiaf ; often, it is true, wry slight, 
but mifficivut to dctosunc gouty aotion to tliisa parti. 

Owl^ (f^eeliotiM t^f the frinmy Organs. — It is 
uncummOD to find gouty puticate oomplaiuing of much 
irritability of tbo blodcler, somotiinos aooompuiiiiMi with 
on incroasod discliurgo of mucus, and generally with 
scanty and Ligh-colvurod uriDo, giving lim to a ooptous 
untc dcpoait on cooling. Suoli ej-uiploms oiUiu occur 
iu tho iiitcn-als of gout, Domctlmea in aubjeeta in 
whom rvgulur gout had ncvor developed itself. Sir C. 
Seudamoro itilat« omos of tbo former kind in which 
Qiflre was a purulent dischaigo, rolievcd by the oocur- 
nenoe of gout in the feet ; but from tho description of 
the nrticuliiT offoctions in some of those instanccB, I 
should be iudinvd to question thuir strictly gonty 
character, and should ascribe the discharge to other 
OBiUKS. A few years sinoe I was consulted on the 
case of a geutlemau who was suffering from the 
following s>inptoiDs : great irritability of the bladder, 
shon-u by constant desre to pass water^ and inability 
to sit still for many minutes ; urine rorj' aoanty and 
thick from a pale deposit of urate of soda, olosely 
resembling pus ; pains in tlio hips and much palpita- 
tion of the heart ; so marked were tho symptooia that 
the prceoncc of a stone ia tho bladder hud boon 
poctcd by his medical utti-ndaot. From tho hi 





ArFECriNG THE UBINARY OBGASflL 



SOB 



h 



of the coitc it iip])cur(Kl tliut during Uiu lust year tbe 
putioot's littbitij of life had be<,ii cuti»iJombly ctuiogod ; 
iiutciid of taking much exercise and liWog plainly, ho 
hjui led u comparuUvcly inuotivu lifo and lived freely. 
From tbcso circumt^tdiiL'i.'-s I was induced to suspvct 
that tho symptonui depi;iidud on a gouty habit, and 
txcatinunt given with a view to currcct liuch soon 
proved completely suceceafcU. Dr. Todd relates a 
etutc of cystitifl apparently connected with the prcaence 
of }^ut, and many other instanoea in which the bladder 
has been involved arc on record. 

The kidneys appear occasionally to ho attacked 
irith gout, and when this takeo place there is pain in 
tlio back and other symptoms found in nephritic forms 
of diiieasc. From what lias been stated in this iirork 
vitii regard to tlio nltt.'rcd ntructure whicli these organs 
•xhibit in the majority of eases of chi-unic gmit, it is 
not a matter of surprisi- to find indications of its cxts^ 
CQce during life. My uwn ubeenutiuni; load mo to 
think that true gouty inflammation is »fl«n set up in 
the structure of the kidney, accompanied with dcpoats 
cf antto of soda, not merely in the interior of the 
tubnli uriniferi but in tlie fibious tissue itself. It may 
bo that this structure, from the circumstances in which 
it is placed, being in constant contact viih a fluid 
having an acid reaction, is selected as the early scat 
of gouty depoation ; that it is frequently so choeon, 
proof has been afibniod in the fact that white points 
of uratu of soda were observed, with few uxceptioos, 
in the pot4 mortem examiuatioD of these organs. 



SM 




nutsorun govt. 



Although tlie boll of the great toe is apparcntly 
Bdeoted by gont in the majority of iostanoea for its 
first tDranoD, it \s <]mte poAsible to oonoeivc that the* 
fibrous structurcfi of tho Iddnrii'H may occofflonally take 
the prcocdoiioc though not rcoognisablo by auy iittb- 
jeotive phenomena ; thia is sometimea the ouo vitli 
tho heart iii acute rheumatitim. In many oasco of 
aitiedar gout I have known the urine to bo nlhu- 
minoos for n time, but aflcnrard.'i to be quite fl 
from this principle ; in some of these instanoos, 
albumen may hare been due to the t«nipomry preeonee 
of gouty inflammation in the renal orgnnR. In • few 
putioDtti I have found that »!vere paius in the bode, 
inexplicable by tho presence of nephritic calooli, have 
preceded the development of gout in tlio joints, and 
have been speedily relieved by its occurrence. 

Iostanoea nre on rocord in which the prostnte gland 
and testicles have apjieared to be a£focted with gouty 
inflammation and K])ii»in, and the sjinptoms to have 
been suddenly rvlievod on the occurrence of goat nf 
tlio extremities ; but I ftUftpcet that In most of these 
cases other mischief liai« been prosenl, and tlio symp- 
toma wore only modified by the existence of tho goa^ 
diathesia. 



,of 
htt- 



Gout of the Etfe and Ear. — A form of ophthaknin 
connected with gciut hna long bocn recognised, and 
appears to be tolcrnbly well establidicd, bat as rheu- 
matic inflammation of the oyos is oquidly allowed 
to exist, difKcultio^ may ut once arise in tlio diaj^nosis. 




AFFECTIKG THE EYE ASD EAK. 



eOT 



I 



I h«v* t»-itncs*od many cases in which conjimctivitiB 
itnd twlorotids appeared to be distinctly connected with 
the gouty diathesis, and instancofl nre recorded of the 
alternation of ophthalmia with inflammation of the 
joiuU. Gouty iritis ia also said to occur. 

Our infonnation on this subject may be thofi 
mimmod up. Patient" having a well marked gouty 
diathca-s now and then cx{>crienco uttaolu of inflam- 
mation of the difTcTcnt Ktraoturcs of the eye ; and it 
is important to bear in mind the fact that the state of 
the habit may ooiL'^idorably modify and keep up such 
aflfections, and also that treatment directed to the 
morbid condition nf the syRtom may prove very 
effectual in curing thn local mischief. 

Frequent referenoo hoe been made to the preaenoe 
of little nodules of unito of soda upon tho cortilBges of 
the ear, and it has also boon ootiood tliat patients 
oooadonally experience paiiu in tho ears prior to an 
oidiuarj' fit »f gout. Dr. Qrave-i, without mentioning 
tho appearance of these timall chalk-stoncfl, ro&rs to 
the twinges in the ears, but attributes them to mo* 
mcntaiii' congestion, and alludes to a gentleman whoso 
ear was sometimos so attacked with agousiiig pain, 
but which never lasted mora than a few honn: Dr. 
Graves himself also suffered from similar attacks, 
which disappeared on the ocourrence of gout in tho 
fingers. 

When deposition of urate of soda tokos place in tho 
Bbro-c8rti]agP of tho c«r, but little disturbance enstus 
compared with what re«ult5 from the pruscnoe of tho 



puroxysm, GommeDciiig with infilt 
nud subiicqumit iiiQiuumution ; the 
guut ill tlio car and in u joiiit dep 
little intliuninutory octiuii in Iht' f 
from the indifiei'CQcc of tlio fibro-c 
soncc of the foiviga body. 

Deposits are not unirequenUy foi 
and DSBicula of tbc cor, and ha 
pointed out by Mr. To)~nbec and \ 
several cxtuuinatioofi of these parts' 
disoorer b trace of uric iicid. Whe 
connected with gout)' intianuuatioi 
matbcr of unoert^ty ; they eho 
sought for in gouty subjects in whi 
much affected with chalk-stones, ft 
such eases it is not probable that tb 
any others. I urn iudiucd to regt 
whidi I have rccii in tlic bones of tl 
the prcicucc of a dij<ctiw more reset 
arthriUtt than true gout. 



AFFEOiq|C TBK SKIN. 



509 



I 



if cutaneous <li8tfascs OT«r occur in direct dependence 
upon a gouty stuto of the E>-stcm, and it irill bo found 
in the sequel that thorc i-< much evidence in favour of 
the idoa. 

Dr. Graves, in his Clinical Lectures, mentions that 
he has met with a sin^liir affeotion in connection 
with gout, and quotes the case of an elderly lady 
of decided goutj' habit, who was liable to a daily 
poroxj'sm of the following character. About three 
o'olook in the afternoon, her noee became hot, and 
the heat continued for four or five hours, the skin be- 
coming first of a bright red then of a purplish colour ; 
this redness spread to the upper part of her cheeks, 
and was accompanied by uneasiness but no pain, and 
always subsided about the same hour in the evening. 
Sir Henry Holland asserts that he has so often seen 
psoriasis prevailing in gontj' families — sometimes alter- 
natbg with acute attacks of the disease, sometimes 
suspended by them, sometimes seeming to prevent 
them in individuals thus disposed— that it is difficult 
not to avign the same morbid cause to them reeolts, 
however nniutcUigiblo its mode of action under Koeh 
difFerent forms. Several instances of skin disease in 
connection with gout have come under my own obser* 
\-atinn. some wore cases of prurigo, chiefly in females 
shortly after the cessation of the catamenia, others of 
chronic eczema and peoriluns, which have either alter- 
nated with or aeooatpanied regular articular gout 
Pruritus an! U also a s>-n]ptom froqucntly met with 
in gouty subjects. A cose of eowre eczema ap- 



CIO 



IRREGULiVR GOUT. 



poaiing to ctei)ciKl on a goutj' state of ttc tij'stcRi has 
como under my notice. 

A gentleman having cxpcrionocd »:vcr»] attacks of 
gout within » fthort period of time wu put under 
treatment, and by this means the articuUr disMse 
was quite subdued ; but afWr a few months an eruption 
of eczemn be^ii to ifhow itself, first on the car«, then 
one elbow, aftenraidi spreading to the side of the faco 
and other paits of the body : the eruption appeared to 
be made woriie by the ai-.iMiical solution, but to yield 
to a treatment adapted to the cure of gouty inflam- 
inntion. 

Ooift affecting the Nercom mid MuKulav Sfftffm*. — 
During the progress of regular gout, moro especially 
the chronic varieties, and sometimes without the pre- 
vious development of the articular disorder, symptoms 
indicating ii-ritatioii of the nervous lutd musculir 
systems, and clearly referable to the pre.sencc of • 
gouty diathesis, are exhibited. These manifestations 
arc generally of a functional character, hut are 8om<^ 
timea dependent on inflammatory action which appean^ 
&« &r as can 1)C ascertained, to be of the same nattuv 
as true gouty iniiammation. 



Cramp. — TiVe have already had oecafdon to notico 
cramp as a frequent premonitory sj'mptom of a fit of 
gout, and it is one to which gouty subjeots arc very 
liable, not only during an attack, but likewise in the 
intorrale of the paroxysms ; and in certain coses tliis 



fc 




I 



AFFECTING THE MUSCi.ES. 



s>'niptx)m is increused to such an extent as to beoomo 
a eoiirco of serioiu annoyanco. 

Somewhat alliod to cramp is a peculiar afTeotioii 
noticed ill certain gouty subjects by Dr. Graves, con- 
sistiiig iu tiu insuperable inclination on the part of the 
patient to grind his teeth ; this desire appears to origi* 
iiate in a disagreeable uneasy sensation in tlie teeth 
tlicin&clvDg, and ia for the moment alle^'iated by 
forcibly grinding them together, but immediate jr 
returns when the patient ceases to perform this action, 
and is therefore continued during the entire day when 
the disease is confirmed. When a,sleep, the patient 
no longer grinds his teeth, the grinding being in all 
cases the result of voluntary motion. Dr. Orarce 
gives details of four persons so affected, and remarks 
that as this grinding ooutinnee for years, it produces 
great ohanges in those organs, affecting sometimeB 
one ode of the jaw, mmetimea both ; so that in con- 
Srmcd casco, Uie teeth are grotmd down to the level 
of the gums. Ilsving witneesed many instances of 
this kind and all of thorn in persons of the gouty 
diathesis, he is inclined to attribute the ^mptom to 
the i'xietonco of gout in the constitution, and iU effect 
on the dental nerves. 

Ono of the cases relating to this subject, contained 
in Dr. Graves's Clinical Lectures, is as follows : " A 
gentleman, af;ed 45, nlightly made, muscalar, and bom 
of healthy porents, was attacked with shivering and 
loss of power of the left side after a severe wetting. 
Uo recovered ondcr appropriate troatmest, but in 




to pU la tMth, wUefa 
iB«itaBtMlo pnm ai 

In u flttB 

fjnrtoB witb miiLiuy sbo iuIihIm 000 o> nv 1 
■11 witb mmiawhle nUet, vlncli bi^Bd bz 
HathMbacBDewbadMsravaiidaprlied loi 
■DMHiif vbo oiH mo 01 cvB^nwiB, viQkme i 
lod lobnqicntlj, to • tliin] pnctitifncr, «1io ■ 
•Ifibao to levdiiii^, bliitiring, putvbtion with 
MBctic, mid Tuimu odwr nmedia^ bat wilhoot on ■, 
fcraofmblo rviraJt. All tbis time hu "«*^iml altM* 
diiDts, «> far fmtn nupeetiiig tbc pnncpee of 0Di^ 
ridiculed tKr idi-n nf its f P rt caw. Alkoat tlifW 
nunUu ^0 tkis gmlkouui cnoia to Dublin, weal to 
diae at tlw faoow of « ftimd, md with Mnne «tt«| 
napped Ute at night nod drank whifkoy-jnmch. Not 
day ho had Tomitin^, purging and epigastric tmder* 
ne<n, uut on thu day afUr, the hall of hw grmt W 
becamo swollen, hot, and cxquioiloly painful, Iraring 
110 donbt as to tho nattuv of the affection. In tUi 
gonlloiBBn't eaao the grinding of the teeth is not con- 
utant, bat is always greatest when the atomnch U 
most dcnwgcd. The teeth in the under jaw arv dl 
mand; three or four of tliri molani of the iippi^>r jnw 
hare been extm^t^d. Tlic four upper incuois am 
groand nearly half way thmugli to the gum on the 
onu ride, while the otheni arc very little worn. By 



AmCTIXa THE MDSCLER, 



M 



prmtifing the iongue agninst tho upper inciBOi*, or by 
toocliing n oortaio point of one particulur tooth, ho 
eon at niiy time iirivst tho t4.i]tltiioy to grind, luid can 
8iisp(!nd it lis loug iLt pressure is ooiitiiiiu>d in tho 
nuuincr just dncribod." 

Fnim ii card'ul pcriiml of tho cuscs dt«d by Dr. 
Orevf^ I must confi-SH, tliut I am l>y no iiiL-nns oon- 
Tincod that the poculiitr s^inplum di'i>cnljL-d by him, 
the grinding of the tcoth, is dupcndcut ou tltc gouty 
stuto of tho systfin, but should bo more indiiiod to 
look upon it lu connoctod with a pi.'Ciilinr fi*nii of tho 
dyspppsia occurring sometimes in gouty liubitit. 

NeHralgia \» not an uncommon munifcstution of 
gout, and may occur in various situations ; somotimea 
the bniii4:bMi of ihtf fifth pair ore implicated, and fre- 
()UfiitIy the sciatic nervo, and moro mrely oth«r 
epinul nerrCK. I hare m«t with many im^tauoos of 
theao different forms of neuralgia, whieh arc oxooed- 
ingly diSicult to diagnose, unless ullematiiig with, or 
■kcoomiianied by. joint disease. Local |iara]ysis ap^K-ars 
at times U> doiRiid on the extstcnoo of B gouty habit, 
and a ca.4e of facial [wmitysis onco came under my 
own care, which di«i]>[>eaK-d on Uio occurraii-o of 
regtdar gout, and the patient was afterwanU subject 
to the ordinary* forms of tho disease. In such in- 
Btaiwctf, it i.-( B qucstiom if the neuralgia or paralysis 
is induced aiinply by the impure slate of the blood, or 
whether a rml inllainin*tory action is set up in tho 
shcuth of tho ncrros or the fibrous covering* of tho 
spinal cord. 



V V 



oil 



IBBEOUUB GOUT, 



Sj/tttriti and ITypoe/u)niriant.^S<HaBiiniV9 the 
development of liyHttritMil symptoms is eoiucd by a 
gouty state of itylom mid U-oomoa rdicred by thr 
oecuTR'iictf of ai-tii'ular gout. Suot instances kro 
usually siH.'n in wnmcn wlio strongly iuhcrit gout. 
ejpooiiilly when tlicro i^ an irregularit)* in the cata* 
monia, or soon ftftcr tlio period of tbdr coxwitiuD ; 
in such cases it seems to dt-jx'nd on an inipun- condi- 
tion of the blood, but thero anj w-anting the exciting 
caUBC6 aeccxiary to bring about an attack of n-gnlftr 
ant. I hare seen scveraJ caaca where thu Bpinal 
tenderness and artindar affectiou clcariy altei-uat«d 
with each other. In the male, I have in wvcral 
in^anoes scon n'oU-niarked h)'pochoudriasts, ubriouaty 
connects with the gouty habit, and reUvvL-d by the 
occurrence of gout in the joints. 

In some patients it ecems prohable that a Swty 
oandttion uf the ut«rue or its appendagt.<s, may bo the 
primary cau3C of the hysteria. 



IftadacJte. — A forcible illustration of tho eonadOtiOB 
botWM-n bctidiurliv and a gouty eoiiditimi of Um 
syatAin u seen in tho fullowing case. A lady, sixty 
yean of ngo, harin^ inijoycd very good health idl bcr 
life, oonxulted me on nceount of ti very intviim' heoil- 
aeim, from whioh i<)ic had suffered about wventt.'cn 
dft>'8; the [iiiin was felt chiefly at the vrrtr-x nuilbnok 
of the hcati, iind was somewhat [>eri(>die in character, 
nft<'n lasting about an hour, then oeo-iing for two or 
tliDH! houns mid nguiu retuniiug; however, fur tko 




h 



APPECTINO THE NEEVOITS SYSTEM. 51* 

last two dixys prior Ut my liocing; ber, tbo pnin had 
been eontinuotis. On «uiinitiatiuo it wna found that 
(btm was distinct brat and tondcraesa uf tht- pftinful 
part. This lady hiui never t-xpericnocd any gout, and 
I oonsidored th« affeotiun at first as Iiysturicul, and 
prescribed accordingly. IIowctoTiOd tbi- ni-xt vvt'Oing 
the pain i^uddcnly It-ft tbo head, and the ball of th« 
left gn-ut too bvcaiuo acutely painful and tt-ndcr, and 
after a fow hours, swollen, red, and sluning on tbo 
Eurfaco ; in fact tlm patient was soBtring simply frrmi 
a eoveiv attack of gtmiiinc gout, which ran it^ ordi- 
nary counte. A socond lit implicating the same joint, 
occurred after a few months, hut not preceded by any 
headache or other irregular manifeslation of goat 

Epiifpty, Apoptery, Mania, ^e. — More serious afieo- 
tiona of the nervous sy^fina occ^onally arise, depend- 
ing on the oontrol portions of tha syBtam being 
involved. Sometimes epilcpitY appears to be con- 
nected with u gouty bahit. Van Bivictcn mentions a 
case in wbiob tiic fita ceased as soon as u r^ular 
paroxyHm of gout vtiMicd. and M-veral iustauoes of 
iJte kind have oonie under my own ob<«rTation ; to 
ooo patient, an ol<t man, cureral e|)ili.^tic fits oocorrod 
be£>Te (bcir nature was susfioctt.'d, but in a short time 
joint affection showed it»elf au<l tlio bead symptoms 
ceased ; prior to tbo dcvebipment of tlio artiuubir 
gout, on exnminaliou of tbc hlood, taken from tbu 
tomploa by cup)>ing, hud sbowu the existence uf a 
largo amount of urie acid. 

1, I 8 



MU 



rKuouuiu Qorr, 



In onotW esiw, that uf ■ gcnflcman sixtj-a|^ 
yrmn of age, whn IukI «uft?rrd fnnn mnilar ^mit 
ttr about twenty ytmn, ui oial«[itio fiU Ucting khim) 
liaw, oeeamd, ind in tlw fpaco td mx veok* tlu* wm 
CoIIowkI by B fcewtiil fit ; lot durinff tlw mlarqiu-nt 
two yean And a halt tli«Tv «w on rptum uf Um 
fili^ bat nigalar Brticolar gont, whkh hud boao 
i^wked bdbr* th« on-arreDce of the epileptio wixtirR, 
uanifaMcd ilaelf from time to tune. 

GontT anoia is osoaoonally seen, and ana iastanw 
whinh rapidly aoperrviwd after the rmuu it i on of Ibi 
jutot afioctinn bu Uwo alrrody iiUutlc*d to. In 
■notW «M wlum uliglit vaiideriiig uvvurrcd, the 
iwig w of tho afieetiao waa iolenstiiig; nhowing th« 
pntnbillQr of tba nemhtann of tho bnuo htaag 
a&etol ¥riUi gouty inflanunatiati. 

A gvnlJt<nuui inilijccted to gimt nuntal nnri Ixxlily 
fatigue, and likcwiM expo«ed to cold, bccomo ill ; bia 
h<md wa« hat and jiainfiil, he waDderMl at night ; in 
addition to which there was coosidenihlv febrile lUi- 
turbaiicc; ttu* eembral nrraptoms did not yield Id 
onliuaiy trwtmcnt, but saddenly di»upi>i-art'd, wh«D 
one of tho great tura becune affectt^d with oeiihi 
gout. Thi« imtient hud very occasionally btwji f)ubjii:t 
to slight nttjicki) of rf^lar gout, but these had been 
oonfin(>d to tho gn>at toes. 

ADothor gootlnnan has n-ceotly been under my 
oarc miflpring from gouty tnaiiia, and lus oaae is nut 
doToid of iiitorcflt. He is over seventy years of ngt>, 
and has for some lengthened period been subjuct la 



rib 



AFFECTING THE SERVOUS SYSTEM. 



<17 



articalar gout, but of no great Bcvcritj'. Shortly iiftcr 
oxpofliuv to <»ld in an open carriage and bt'OOiuing 
clitUed, he ff It gouty pnins and swelling in one wrist ; 
tills continur^ for a fow da^'s, bat suddi-uly diiiii)>- 
pciinil, and htit behaTintir at the i>atiie tiiiic biciiRic 
itlu-n-d, and be soon exbibittxl «)-mpton>« uf c<iiu{>letr 
tncntid derangement. Tliut stato of mind roniitlncd 
f'lr Some wwks, but bis iruson wiis nftcrwurdft com- 
pU't^'ly n-etoffd; thy inBamniiitiim R-tuniiug in tbo 
wri«t and band, and continuiug ubstinut4'ly for some 
timi\ 

In oonncctioD with this subject, I may state, that 
in some attaclu of epilepsy, pandy»b, and apopU-xy. 
occurring in persons nut known to have bad gout, I 
baro found t)io blnott rich id iinc noid ; the value of 
this fnet cannot U: <lL-tunuincd now, but must be left 
to futuKi observations and inquiiy. Are tliese cere- 
bral aiTeotions ever connected with gout, or does the 
shock cauMxl by sudden miwOiiof to the brain or Rpine, 
MUM defective elimination of the urio add by the 
kidneys ? At proseot, I am inelincd to regard the 
lattef view as most probably nirreet. In connec- 
tion with the cubject of cerebral mlTectious, I may 
tint*', tlmt heDiicnuiiai is not uncommon iu gouty 
subjects. 



Gonfy A/Hrtion of Spimil Cord. — Instances of the 
spinal cord Ixiing implicated by gout have occasionally 
been noticed, and a well-mariiod caw has come under 
my own cure in a gentlcmac who suSered &om pom 



M9 



fKBEGtTLAR GOUT, 



and tendemeu in Uie nppor part of tlio lambar epinc, 
gn-At pitin in the lcg«, and hyporantbcsi*. together 
with extreme deprvesioii of tlio eyrton. Duiing the 
mniiifestation of these i!>'niptom«, whioh lasted for 
Mmo weeks, goiit appeared from time to time in 
moderate intoiinity in both great toes, and the result 
of the uuie, which wi» mo«t eatij£K;t<uy, made it 
pmbnltlo thiit it wiu one of gouty infl»mmatio« affect- 
ing the meninges of the fpma\ cunl. I hare also 
reeords of two other cases, in which thv itpinul struc- 
tures iippoiin-d to be attuckod with true gouty iiiHiim- 
mfttiun, though iu a low degnn? than in tlie above 
itutancc. Dr. Graves has abo related some cssca 
occurring in gouty suhjects, in which spinal in-mptoms 
manifiwted themselree during life, and the conl waa 
found softened after death ; but, from any eridcnoo 
shown to the contrary, they mif;ht have been ordinanr 
cases of eoAoning of the spinal marrow ; in one 
instflseo, it it stated thnt some relief was nifonloil 
when gout appeared in the feet, but this most not be 
taken as an abeoluto proof of its gouty elmraoter, 
seizing that tlie n'licf might hare been duo to tlw 
dniviiliro effect of the inflammation in a diKtaat 
part As to the appearance of deposits of ourthy 
matter upon the meninges of the bniin and cord, 
■nd iu the shcath.-i of tlic nerves, I may i^tate, that 
in no imtance has it been shown that they were in 
any way connected with gouty inflammation ; tbojr 
probably consutcd of phosphato and carbonate of 
Um^ and not of urate of eodu, and the fonnor salts 



TKEATME>T OF. 



n» 



iicror oc!<>ar m Um products of tni« gout ; for when 
lime salt--* hnvc U-oii found in gouty cuncrctioiu they 
have redulti'd nthor from Uio tissoca in which they 
have occurred, or from ordiiiaty iofluomatioD having 
boon sot ii[i urouod the tnic gouty dt^poisits. 

Aa in the cue of other supposed abuonzud forms 
of |^>ut, so with afTvctioiu uf ttio bruin und iqnno, w« 
mut^t be estremety cautious in mukiiig our diagaoajs, 
uiid romcmlier that Berioiis organio miaduaf nay 
occur in the central parte of tho nervous system ia 
gouty suljijout», and :<till ho c!#(.-ntiidly indopeodeot of 
tilt' dintliL'viM. At thu samv tinii-, wlion such nuschief 
occurs, the ordinary <tvvclo)>niviit of ff>ut may pro* 
bably )jc nioru or li-« chtniked ; it is also probable 
that tlie ccrvbrol alfoctiun, ulthuugb not depoodeut 
oil, may 4liU bo modiSod by, thu gouty state uf the 
habit. 



Trmtmmt of Httroctdtnt Oout. — Tho treatment of 
rotnwodi-nt gout ia simple ; and vro must Lc guidod 
in each enac by tho knowludgo vo can obtain of its 
I real natore. If the ftumnoh be atfoeted, and them 
Fis no evidence of the existctioo of inflammation, W 
shown by the vant of febrile dL<>tar)i€uico, tlio eon- 
dition of the tongue, aud tho abmiicu of tondsVDMi 
on pressure, then stimulants, as ether, chloroform, 
ammonia, and aromatic^ may be admiuist4>red, and if 
the pain bo vi^ry intense, opium. Vomiting should 
h1<k> be promotod b>' diluents, and oouuter- irritation 
applied over the epigostriuai and left hypochondhum. 



GSO 



IRItEGDLlR OOtTT. 



Brandy la sometimes of greftt use, bat it U well not 
to employ stunulants too liberally, as llie eymptonu 
often yield to rcmedios less likely to bo followed by 
miwhief. If tlicro bo pvidenco of an inflammatoty 
Btat« of the stomach, loeohes, sedatiros, as hydrocyanic 
add, and alkuliu«, iinj iodioiUul, but sucb cases nro 
very roic. 

At tlio time wo ore employing tlio remedies jtut 
enumerated, wo .thoulil not neglect to pay attentinn to 
tlio extremities, fwr, by the vac of warmth and 
counter-irritatiou, we may frciiui-ntly bring bnok tbo 
inflftrnmatinu to tbo«o parts, and thus ntliere tbo 
rctroecdeiit afft-dion. 

When the heart ii the «eut of rctrocodeooe, the 
same romodit'S may be appliird at tbe commenocmcot, 
and ci;ntiiiued until the. doiireK-ion of the vinndutinn 
bus bci'ii removed ; when the bend is imptieuted, 
eimilur troutmeut to thut which would be adopted is 
the oorrcTtpouding ufibctionis if tht-y oecurrcd in other 
subjects, must be resorted to, hut somewhat modified 
by our kaowlodgo of the existence of gout in the 
Eystem. and of the propriety of endcarouring to oanso 
its return to the extxemitiee. 



Treatment of other forma of Imgular (Jotil. — No 
simple method can be given for the treatment of tba 
variouit fonns of irregular gout which we hare 
dewribed, as it must necessarily differ much in dif- 
ferent cases. Some general rules may. howerer, be 
laid down for guidance. In coses in which the beart* 



J 



TK£ATUENT OF. 



m 



lunj^. urinary organs, or nen'oue system iiro affected, 
as these are parts of tlic bmly of great importanw, 
it should he our endeavour lo givo relief by iiiducmg 
gouty inflammation of the extremities, an object hwt 
iiccomplifihed by Uie application of warmth nad 
niodiTute counter-irritotiou lo lliesc purts, M by Iiot 
bottles, mustard poultices, imd other similiu* uppU- 
cutious. 

Wc Hhould also urn at correctinff the gouty 
diathesiji, by the employment of the rarious retne- 
dial means enumerated in the trentmcnt of chronio 
goat, but at the same time wc should carefully avoid 
producing any depression. 

When there is evidence of the presence of inflam- 
matioD in any important oi^Mn, local depletion may 
be nocGnniy, and the case muy be treated as ordinary 
inflammation ; but it tihoiild always be borne in mind, 
that a peculiar state of the tiytttem is present wbioh 
modifies to a great extent tlic symptoms, and demands 
peculiar mean* for its rcmovul. 

The value of coldiicum in tlio irregiihir forms of 
gout has not bet^n quite satiiifactorily ascertained ; 
Sir H. Holland is of opinion that its influence is not 
limited to the removal of gout from the joints, but 
extends to the relief of the disease, even vhea it 
assumes Uio most irregular and ehnngenble aspt-cts. 
My own experience accords completely with that of 
Sir H. Holland, us regards the value of ootohicum in 
gouty inftomBiation of the articular stnicturrw, but I 
liaire not yvt sofficivnt vvidcuco to enable me to decide 



E22 



IHREQULAR GOUT. 



whether the remedy is potent in removing Fymptomn 
which are simply functioiial, or entirely indt'pendent 
of inflamiaatory action ; at the same time I am con- 
vinced that ite judicious emphjyment tu most of the 
irreRulcir manifcBt is attended with very 

cousideraUe adva 




^'/y 



^ 












» 



^ ■ 



'i'i>..^ 






■^J 



* 



..l^/ 



J 




i ■% 




« *;. . 1: 


v.% 




• !* 




s 




1 




>d -- - 




v-" 


^:^ 





'?:; 




CHAPTER XV. 

EnRCHiTie Oour:~UKAiu on m» ifi or nil vivt-wiitDmi) 
jutiii4 rnoM Tflt sarLoraMt o* tni nmn — pimmnn 

I>UI4t«» HCLOtilD VI>I>H TUB KtlU 0» MlWXiinC DOIJT— «Uli 
or THUS OOOt TO WBICK tll« tlTt« l» OITWI— C*m or CT»-JlCWI 

Kncraim — Pu«3a»i> or onot mn HHiiiHinm — cinrut 

■MICaATIWt—MICrHlTOID 1«TII»III»— !■■ OIIMIIW UI«ClliTIC 

Aktamnm or »D*m— »vii>o»itt or twi Joisw or a»toi«tii — 
■THnoxt — AVtraMicti cn*Ki«TiM — eiDiu — riraobMT — 

MtOmSIK — T1RI.1 RXKIkltlXa tilt t>im»IITIJLl. MAOaOMt Of 
•Oft. UtLriUTIaK, *>» kOItNlTOIP iBtll«JTI»— mMTKBWt OV 
■MtrmTIC OOOT— ILLfrTRATlIK CL1>U Of I1>I»11UT01& jmiUTm 

Tint tonn rlicuniutic gout is applied to so many 
diflcn-nt fomi« uf disease thut it is cxoec4lingly difficult 
to define what is intended to bo undi-rstood by it. 
Tho cumpuund uiunu would naturally imply tliiit tho 
diaonlor iW-lf was complex, and tUat it (lc|Hi)dod on 
a union of tlio two sepuratv discuMt, gout nod riteu- 
inattstn. Tlio nauut ie oil«n vmployttl under this 
sap[>oeitian, but in many vbrks on tncdidiie the term 
is used to deHignate a diwaac differing altogether firom 
either of theee affeotionti, aa far &« its intimate patho- 
logf is coooemed. 

Under these circumstances it will bo ncceaauy to 
ntter umewhat fully into the characters of the 
diseases which hare been thus confuumlod. and to 
point out tho UH-thod of dearly distiogui«hitig emit 



BHBCMATIC GOUT. 



of them. But few authors recognise thp combiniition 
of gout and rhoumatUm, and many arv strongly 
opposed to the doctrine of their nnion ; no muntioQ 
of it is made in the works of Bocrhaiive, Van Swiotco, 
or of Drs. Cullcn, Heberden, or Watsim ; Sir C. 
Scudumoro rrTiiaiks in rcferonee to tliis subject, that 
toxLures which havt> been long aSectcd with goot 
hccomo 80 weakened as to be wry su.wcptib1e of 
vidfisitiidd* of tcinpcmturo, and thua tho lU^inler may 
partake of tlic diaroctor of rhoiimntism. It was only 
in thiei way that lio could attach any propriety to the 
vor}' common expression, ri&auuitie gout. It voold 
aj)ppar from tho above that the term is often employed, 
but wldom attcniptvJ t« be accurately defiiiod. 

Our fiT»i aim \a the proscut chapter will be to state 
succinctly the diagnostic chartctor of gout and rheu- 
matism both in their aonta and chronic forms, and, 
aftorwarcU to describe certain other discasM vhich 
have boon callud at different timc« and by different 
author; by the name of rheumatic gout. To make 
a correct diugnosis of these disorders, »o frequently 
mistaken for each otlier, i» of groat momcut, OA their 
appropriate treatment is of u very diffcrc^nt chaniotcr. 

Gout caunot Muctly be niislukoti for acute rlu<una' 
tism when each maludy ik exhibited iu its typical 
form ; Ibu subjects in which tho disdoms osnaUy 
occur differ considcmbly, the first being most oommoa 
in men after middle ago, and in thoiW who have lired i 
frct'ly ; the second is at leaitt as frequent in female*,' 
usually in the young and those of enfeebled powers. 



BnEl'MATIC OOOT. 



MS 



i 



Tho charact«Tfl of tho discnactt are aim dLsslniilar. 
Gout, in its onrly seizures, vnliiiurily affects but ono 
or two joiiitis oud commouly Llio Lull of the great 
ix», and tho inflttminatioD ia aooompaniod with coio- 
poratirdy little Eevcr but with much local pain, 
redoma, and subsequent destjuamation of tho cuticle ; 
the attacks am for the most part peiiodic, and 
gradually implicate a larger number of tbo joiuts. 
Rheumatism^ on (he contrary-, geavrally oflcctA mauy 
and large joints, even at first, and the upper cstre- 
mitiee equally with the lower ; the fever u likewise 
out of proportion to tho local inflammadou, and, 
oltliuugli the diacoae is apt to return upon re-expomire 
to tt« exciting causes, still nn periodicity can be traced 
in it8 visitations. Gout may be turthcr separated 
from rheumntLnii by tfie study uf hercditar)- influenoo, 
of the prcdisposiiig and exciting oouwm of tho tv-o 
di»easi>ft, as likewise of the gn«t tendency Ui acute 
oardiae offuction in the latter. Kotwithstendiug tho 
apparent facility in the diagnosia of typiool cases, 
tliere are others very ditlBcult to separate ; some such 
we huTi> given in our description of acute gout, and 
tlioAe require different methods of aualj'sis, involv- 
ing a knowledge of thetr more intimate pathology. 

In gout we have proved beyond question that the 
blood is invariably impregiuitc<l with uric acid, and 
wfi are in a poeution equally to prove that in geuuiiu) 
acute rtieumatiMm this princiido is ubMmt ; in oo 
examuutioD of forty cues of tho hitter dtwuo ex- 
Ikibiting nil its t}-pic«l poculiuitio*, th« odieut point! 



SK 



RHECMATiC OODT. 



of whi«h will be found in the Appendix, no trace tnu 
diMiivered by the process before detailed. 

Furthermore, we have demotutrat«d llint tntcgou^ 
itillnmniiition is alvayB aooonipauied with the do[ 
tion of unite of soda in the stniotures pritnarily ii 
flamed, and from the examination of the joiuU of 
DumerouH subjects who had suifcrcd during life fixim 
acute rhcumatixni I cau testify that do such altcmtion 
ever cn^ucK. 

The fonncr of theM! means of distinguidung gout 
from rlu'umatisin can often bo mode aviiilnblv for 
clinical purpiiscs, eitlicr by an examiootiuu of the 
bluod or blister Horum, the latter can of course onljr 
be of service in pathological iuvestigations. It muat 
be remembcr«d that these methods of diikgnosis are i 
positive only as ru^trds ];oat, but ti<.>gative as re^pmla { 
rheumatism, for the absence of the above named ^ 
phonomcnii will in no way separate rheumatism from 
othor dideoaes witli whiuh it is sunietiaic« confounded. 

In the chrouio stage of tJie diseases, the separation 
of guut and rfaoumatifm by tliv unlioaTy symptoma 
which present thL-niselvos, becomes in some '"'*«"fift 
u diiticult tusk, even lo those who have giveti special 
attention to the subject ; the forms most apt lo be 
mistaken are chroiiie gout ulfecting both the lar);c and 
small joiuta and onocoompanied with aoy external 
deposits or chalk stones, and certain forma of sub- 
Bcuta rhenmatutm whcro the siime stmctorea an 
implicated ; the external phenomena an> then almost 
the same, probably but little febrile disturbaooe is 



KHItntATlC OOUT. 



Ml 



prarat, tiic joints arc but i^ligbtly swollen, itrul tlitro 
is no rcdiwss of Furfiico. 

A coTL'ful invo«ti;^tiun of lh« history of Ihp cases 
will <]o mnch : if thv di.H>n»o oHj^iiaUjr coinmL'ticcd 
in tho gtvttt toe, nnd grodtmlly bdcanio more t-xtvodod 
in ftftcr attaclci ; if it l>cgan about the middle age, or 
bordering ujxHt this, and the ptiticnt had lived fr«cly, 
induing in win« or omit liquors ; then it is in all 
prohahility a eaae of gout. In numy snbjcota the 
ctaminntion of the extcmal oar will throw ooosidenble 
light, and 1 have often been ablo to arrive quickly st 
a correct diagnosis by finding tho prosonce of a spot 
or two upon the holix. Plate I. fig. I, ropracals the 
oar of a patient haviog but one external deposit, and 
tho true natare of faia ease vtut Uius ut lirst discovert-d, 
and iu tho chapter on chronio gout other cases will be 
Ibtmd iUustiative of tlie above remark. Instauoee 
ocfiasonolly occur in which the history, from peculiar 
drouinstances, is of little value or cannot he procured, 
and where there are no external signs on which tbe 
diagnosis cnn bo founded ; these are rare, but any one 
frequently consulted on &uch subjects must have now 
and then felt a diSwult)*. In nomc of th«M CMM I 
have derived much assistance from an examination of 
the blood or blister fluid, and a carefol attention of tlio 
effects of drugK has often offurtled mndh iKJdiUonal aid. 
as the inHanimatiou of goal is relieved liy tho ndmt> 
nistration of cotchicum in an infinitely more decided 
nuouKr than Ihut dependent on rbetimnti^ni. 

Oetobtr, l&ti2. Au intettatang example illuiitnting 



«} 



RHKCUATIC GOUT. 



tbo diilioulties of making n diognoeis in ocrtein caaes 
of joint diicoao. taii tlio grcnt advantage derirod from 
the examiiiAtion of th« »oriua, is now undor my care 
at thf hnttpital. 

A uuiu, U. U., aged forty-nine, a Oorman, has lived 
in Engliuid fire ycun ; by occupation a mancian, oftea 
ptsying in the streets at vatoring pliico«. 

Hia &th^r died of phthisic, lus putcmal grandfather 
was subject to guut. 

Raring the latter part of this seamn, when at 
Ramsgati', tbo wonther was stormy, mid the pationt 
often cspoiwJ to wot for hours together. 

One day bo inifft'red from great coldness of hia 
fingers and tooR. wbiub, however, soon bcoanic painful. 
hot, red, and oxqul<tti>ly tinilcr, and Uiis ibiia coo- 
tinueil without inipruvement till his rutum to Londoa 
and entry into the hospital, a period of about ten ilaj^. 

When admitted liis condition was as foUoirs : — 

The middle finger of the right hand is the innst 
painful and tbo most swollen, next to tiiis the fore- 
finger of the left hand ; this he attributes to the fact 
of his hanog carried hcai,-y musio-boobi when his 
fingers were quite uumbcd, the chief weight resting 
npon th4;sc fingers. The great toe of tlie left foot, and 
the dorsum of tlie right on« arc also moch swollen, 
redi and very painful, the pains are greatly increased 
at night : the tongue U much furred, Ihvru is loss of 
appetite, and some tbiiiit. I'uUc 68. 

The cose certainly pre^tentcd points of considerable 
difficulty in its diagnosis ; cold appeared to be the 



I 



ElIEirMATIt; OOOT. 



G2e 



exciting caiue, bo had, it is tnio, usually drank a 
littlo porter ouch day, but denied liaring lecn aocos- 
tomed VTVT to tjiko it in oxccsa ; it must be remem- 
bored tlutl until some timo after tils admiaaion it was 
not kiioim that hitt grandfather had suSercd &om goat. 
I was incLiDed on my first visit to look upon the cam 
as one of acute rheumatoid artliritiB, or possibly of 
auh-aoute rheumatism uffc-cting the smaller artieala- 
tiona ; sdll I had my suspicion of its goaty cliaraGtor, 
and with the view of solving the difficulty, I had a 
mall amount (2 fluid onncce) of lilood taken &om the 
■m. The serum of this blood, when examinod by 
Iho uric acid thread experiment, gave evidence of 
containing a Tcry largo amount of urio acid, the 
tlirrads being completely studded vith crystals; the 
oxotnination at once thn>w n light on tlio case, and 
led to its more complete inTostigation, and the taU 
IcDOwlodge of its intimato nature. At first the 
patient was ordered camphor julep tliroo times a day, 
and continued it for six days, at the end of which 
time the condition of the joints was much the same 
as on admission. Half a drodim of colohicum wino 
was then added to the draught, and after a day or 
so ho was markedly relieved by it, and soon beoame 
wett. 

A more aearching investigation showM the pre- 
t«Doi! of two very small white nodules under tlie fold 
of tbi) helix of the left ear, and also of a few points of 
tlte aomo whil4> matter on the palmar surface, near 
the end of the left ind^^x fingrr, and oorcred only by 

H M 




A Uiia cuticlu. ThciM) deposits wcru found to Iw 
tollioo^ imd to coDsist at amt« of Koda. 

IlATiiig shown hov goat ciajr be separated rmn' 
rbcumatifiiQ, the question arises, can tiiey ooozist, 
and iit thora a duoase (o which the t«rDi rkaumaHc 
gout can pn^-rly bo applied f For my own purt, 
although far from doaying tho poisibilitj of acute 
rliSBmiiti«ni attaeking either an individual pfwKiposod 
to gout, or on« having already soiTercd from viiiitn- 
tions of tho disorder, or, on the other hand, nf gout 
niporrening whon- rhoumutiisia has preriouslj' oxiiitod; 
«tiU 1 am oonrinocd, aftvr a long and cortAil stuily of 
the subject, that no combuiatian of tho two disoaSM, 
BB aasumed by tho title, is otct aeco tn nature la 
my own practico, I havo fouod the numo rhoumatio 
gout applied to many divorav maladies, somctimca to 
true gout, when it hait tnivL'lh<d above tlio kQ««e, more 
especially when it has implicated tho upper cxtro- 
mitiea; a patioat CroqaoDtly thus oxprossw himself on 
this sut^ecfr— Fonneriy 1 was suhjoct to attacks of gout, 
but now I am sufloriug fmni rbimniutio gout Yot 
in such a ease his discasK has throughout its oourso 
steadily and chanutoiudcally pntgromed, and remains 
as t>'pical of gout ns on llio day tliat ho first fdt the 
twinges of the too. S»m«timci( thr term is upplit^d to 
chronic or sab-acute rheumatism, mora especially whi-n 
not oonunenoing with rheuinatic fever ; but the t<'nii 
rhvumatio gout is moro commonly given, particulurly 
by tliu medical prolbesion, to a disoaao ha\-iiig a peeu- 
linr ])athoIi>sy, in no way rokted to gout, and not 



nnEPUATniB ARTinciTIS. 



Ml 



iiBDaiBuily to rhrumatunn, and which Dr. Adams, of 
Dubliot line descrilKKt tuuler tho bead of Chronic 
Rhi-iimatic Arthritis, tho nature and firmptonw of 
vhidi we shall shortly coniudoT. 

I should mLTitioD thut now and then, e«poouUy 
when the Urge joints iiro nlonc implicated, gout is 
miitakeD for rhciunHti.sm, and a careful pernaol of Dr. 
Uuleod's liOotuiYS liaR conriiiccd mo that Bonie of 
the eOKfl included by tliat pbyuoian tmder the term 
cap*uiar rheumafitm art) merely examples of gout. 
I>r. Madeod almost admits this himself vhen ho 
states that the extemsl phenomena are often vor>' 
similar, the morbid appearances the same, and cal- 
chictun the specific remedy. If the cont<?nts of Dr. 
MudtyidN wurlcs be uttcntivply examined and analysed, 
much loasan will bo found to doubt altogether the 
oxistoice of • speml diAcoxo vntitlixl to the dudv uf 
eapmbir rhmntaiiwt, for it ii'ill be seen that many 
diffimnt di»urden besides genuine gout are there 
recorded ; for example, aifoctioas conn«ctcd with 
arctbral dijchargi<, and cosm of purulent inflonimatjon 
of the j<nnts. 



I 




RIIRUJIATOin AKTURITIS. 

Cknttk JUtftinujtie Atihritia, Rheumatic Gout — 
Rhiuiiatumr A^iNWHJ-, Umrt Hem CartiJajfc* Arlirttiairrt. 
This affection U dixdnrtly imintod out by lIcbtidRo, 
who >p«aka uf an artiuular disonae, not commencing to 



aa 



RHEUMATIC OODT. 



ih« great toe, but preferring other joints, and i 
progresa diifcring m much from gout, and also from 
rheuroatisni, that it should be distittguished from both 
by some peculiar name. Qeberden remarks that in 
this disease, though Uii> pain is much \ef& violent, the 
swelling is greater than in gout, and its peouliaritj 
chiefly consists in the ^at and laating feeblencaa 
which it engenders, causing the limbs tn be more 
wvakiiiod in two ycar» thitii they would be by regular 
gout in twenty. 

The samo disease is designated Nadoait^ of tlu joiiU* 
by Dr. Haygnrtli, and considered to differ both from 
gout aud rheumatism, and by Cnivulhirr Utnre* des 
eartilagts articulaire*, and Dr. Adams, of DnbUn^ who 
bos carefully studied its morbid anatomy, jvoposes the 
name ehronic rheumatie arihriiU- 

Somctimcs tho aficctiou has rcccirod a name dcpen- 
dmt on its situation, for oxamplc, rheumatic gout, 
when tho wristj«, hands and feet are affected ; ehronic 
rheumolism, whoD the shoulder, elbow, or knee, cither 
singly or mmultaneotislf ; aod mttrhut ctua ami 
when located in the hip. 

Dr. Ilaygarth was folly alive to the importanoe i 
giving to this form of arthritis a distinct name, but 
the term nodosity of the joints hardly expresses what 
is intended to be conveyed, as a nodcee eonditioa may 
be produced by many causes: chronic rfaenmado 
arthritis is preferable to rheumatic gout, for althoi^ 
the disease under consideration differs considerably 
from rheumatism in its pathology, still it is sometimea 



RHKI'MATOII) AKTHKITIS. 



G33 



pxcited by its attacks, and at tiiuea resembles it in il> 
sj-mptoms. 

Dr. Fuller desoribefl it under the name of rbeumatic 
gout, although he allows that it ditTers considerablf 
frwa both affectiooa, for he says. " Rhenmatic gout is 
Dot a mere variety of gout, or of rbeumstisni, nor !• 
it a compound of the two disoases ; it is effiontially 
distinct from them botli, hait u H|)ccial pathology of its 
own, and requireo n distinctir* titlo." 

If wo agree to numo u diwase aimply from ita 
«xt«nial oharacterti, then I udiDit that tho t«nn 
rheumatic gout is not innppropriatu ; bat if we 
advnnou further, and liavo regard to its more iutiinate 
pathobtgy, then 1 deny tbc propriety of tho teno: 
aetiag upon tho former principle, wo should be 
equally justified iu calling suiuo canes of eoarlatina or 
nwBolw by tho compound Icroi of rubeolo-i»aHtttina, 
and w« know that thl^He diseaties were not wparated 
two oeuturic* ago; but we are now ooariaccd that, 
although ono may present many of the charaetera of 
tho other, yot in thi>ir real nature they a]ti>getbar 
difier, eaoh being dcpondont on the presence of a 
specific poison. 

* Although uuviUing to add to tlie number of uamec, 
I cannot help expressing a desire that one may bo 
found for the disease under oonnderatioD, not implying 
any nrotssiu-y retutiou to gout or rheomatiam ; per- 
\itt'[iii RAfumaioid ArfJirititymald answer ttu; object, by 
which t«rm I should wij<li to imply an inflammatory 
aflectioD of th« joints, not unlike rhoutaataam in «omo 




of its fAiamtion, bot diScrbg mulcrinlljr frtno it in tbi 
pntliotogjr. 

I propoM girinff « short sketch of tho dfoetion lu I 
h«v« m>-Milf vitaowcd it, pobting onl uiy diiEiiraooM 
in tho Qxpericnoe of others, wbeo mA an ia- 
ponsBl- 

Bkeaiiiiitoi<l nrthritiii is mnt witli in the you^ 
old, Kinonf; ricJi nnd poor, nnd in both tatm. Dr. 
AdamH oonNKlcni tbil in malM tho hip joint is most 
ofliBctod, in fomal4M th« wriits and h■nd^ and that it 
» miMt oofunonly ibund amoni; the Uboaring pnor; 
hat, on tbo oU>ar hand. Sir B. Brmli« thtnlu that it 
is matt Bommoa in tht upper olamen of society ; a 
diffsraneo of opinioD probably cxplunabla by a diffor- 
vooe in tho «!«■ of pntii-nts moro prominently broqgbt 
under each HtrgMn's notioo. 

Tho afioction, ns far ns my own oxperieneo anabJea 
mo to form on opininn, moro fWNjucntly Aoottra in 
individuals who havo b<<eii exposed to tho ioSuence of 
powerfully dopr««iiiig cauaeft, either mental or phyaaal. 
but when it is cxoiW by acuto rheumatisn), raoh 
anteoedentA may not be met with ; Btill, many oaaoa 
hare oome under my notice, in which the patient waa 
previoualy in apparent good health, and the diaeaae 
hws arisen without any asaignable cause. 

Rheumatoid arthritis oocasioaBUy occurs in an 
scute form, but mora anmlly it assumes a chronic 
diarocter throughout ite whole eonrsc. When aouto, 
it presents many of tlio characters of rheumatic fevnr, 
and in some instances the diagnosia in the early stages 



RlIEUilATOIl) AKTIIKITIS. 



036 



is R matter of considerable difficult)-. Uowover, as 
tbo dtsooso lulraucw the separation u moro readily 
mado. 

Th«ro is URUolly in acuto rluntntiitoid urthritia but 
little of th« Gopioim ohanictori»<tic pcr^pimtion of true 
rheumatiG fever, and, 1 believe, in oU caws, an ab* 
sencc of any inflamtnation uf the cardJao structures. 
The febrile disturbjuit-e again is mucli kw tban in 
wiutc rhcunmtism, and is more in proportion to tlio 
number and importance of tbo iiaplioatod joints. 
Wbcn i-bronic^ the mo^t prominent lymptoms of 
rheumatoid arthritis ore as follows ; pain in the joints, 
attoudiid at first with little or no nwcUiug, ennus 
times incrviL-tod ut night and by hmt ; any attempt 
to move nil aifi'ct«^><l joint augments the ptiiii, particu- 
larly if it liiu> biMm ut ri-st, and patients are Iretiuently 
qaitc unable from this atofo to sbr in bed on fint 
waking ; after a short time tht- joints enhugofiom the 
increased secretion of fluid in tho artieular cavitioe; 
which is usDolly capabUt of detection by imparting 
a Eoft and fluctuating aewiation to the touch ; ut a Inter 
stage of the dlsposp, absorption of tho fluid usually 
takes plaoe, and the swollen joints bevomo gradually 
smaller and harder. 

There is but slight accompanying fever, ami but 
little constitutional disturbance. In some iu!>taDoefi 
the larger jointjt. iw the kne«s, ankles, wrists, and 
elbowa, aro jioculiariy selected, in others, the ADoller 
artioolatiotui only arc attacked, but fniiuonlly botli 
huge and snail joints indiflbrvntlj-. Although this 



«M 



RUEirMATiO OODT. 



ftinn of uilirids is nugrntory, affecting joint afttt 
joint, yet wlum it hu oooo invadt^ Uicm, it seldom 
leaves sny free from misdtief, and when very msny 
joints have boon implicated, the patient ia often 
reduced to a state of miserable heJpleesDees. 

Plate IV. fig. 1, represents the hand of a woman, 
in whom tho diHcose wu just commencing in this 
member, and it will be observed that eerertd of the 
anallar articulntioiu aro much svoUcn from tbo pro- 
aenoo of fluid in the cavitios. The fiM phalangeal 
jmnt of tho ring 6agor esliibits tho phenomena in a 
wcU-murkod form ; sumo distenaoa of thv wrist joint 
will nUo be noticed, depending on tho same oaujBe. 
lu thi« patient tho Ictiioos and other bugger joints were 
BO scrioiiiJy injured, that she was much crippled. 

Fig. 31 refwesonto tho hand of another piitictit, 
Ihe drawing being taken from a iiIaNt<>r cast ; tho 
peculiarity of the defonnily, Uio tmstiiig outwiirds of 
tho fingem, is produced by nrioiu injury of the 
Rnallor artioolationa. 

A more obronic form of the diiwaae, principKUy 
affecting tho smaller joints, and especially tho laat 
phalanges of the hand, is frequently met with. 
Hobenleii baa n small chapter on the subjeot in his 
Connsnntarios, entitled IMgitornm iwdi, and consisting 
fuUowing query : — 

I are those little hard knobe, about the toM) 

^wiiioli uro frcqucTitly sepn upon the fingcni; 

liltl." W'low tbo lop, near the joint? 




cmnvlion with Uie f^ut, being fouiKl 





KHErMATOID ARTHKITia. 



07 



ID persona who never hod it ; thoy continue for life ; 
iLud being hardly ever attended witU pain, or dlxpoBcd 
tn become sores, ore ratltor uusightly than incon- 
veniunt, though they nmst be some little hindranoe 
to the fruo use of the fingora." 




Pij. 31.' 

Dr. Begbio thinks the nodal<» are eonnooted wit!) 
I^t, AT at least that they aro only met inth in what 
he terms a gouty diatliesis, bat he aUoirs tlint tlwy 
oro oftcQ found in those suhjoct* who have never 
ezpttrienoed a fit of gout ; he neverthelc-ffi admits that 

* Pis. 8L A dmalnc tnm • fhitw cmI of a buul m»A dkUrtdi 

ftwil lIlWIMlllllllllfcllll* 



SSI 



HHBlfMATlC CODT. 




tlioso depoeits wpo different from obalk-stones, bctn^ 
ncitlior so soft or fluctunting at first, nor so hard, ur 
onrthliko, m tlic moro ndrnQotid stages; tiwy do not 
a(;i]iiirc ttio Ji^aiiic »\ni wliielt Uic chalky concretions 
Hnmetimcx nttnin, neither do they appear to he ao 
immediately l^noatli the Fikin, nor do t]icy cvc-r burst 
or diadmrge the thin mortar or gritty chalk of tho 
gonty deposit. 

I bcHovc Iloherdcn's stabomont of their having no 
necessary conniption with gcnain<^ gout to bo correct, 
and they aro certuinly found in oth«r eabjocte than 
thoso of u gouty diathesis. I have noticed that 
tfevvnil incQibcn* uf the some family arc froquontly 
ailVctvd with thom, but us far as my nwii expcrtcooo 
gooM, I cannot recall ever having .tccn them iu patients 
who had cxperirnocd a true fit of gout. It must bo 
remembered, tliat I completely separate the Dodolw 
from true gouty depositionH which ho frequently oooor 
iibuut tile lingoTs, but whioh can genendly be distin- 
gui»licd. The diyiforwn riodi of tlebrrden are pro- 
duced by the arthritic diK.-!iac under condderatioD. 
but modi6od by its attacking the Uist phalanges of 
tho ItngeTE. When the disease but advanced to some 
extent, anchylosis, mure or less coinplet«, eniiues, the 
cnd« of the boiiiw arc enlarged and all the surrounding 
etruvtures become thickened and indurated. This form 
of tho afTectioii frequently troubles oldcrly people, and 
is oRea ulteudi^d vritli Koine di«L-ai«e of the hip or utber 
lai^ joint. ¥ig. 32 represents a bund iu irbidi the 
ends of eorcnd of the fingers ore altered in the maimer 



4 



I 

I 

i 




KHKfMATOID AHTHBlTlft. 



just described, and some of the jointe flt-xod nod 
iDimoveable. This fomi of the disease is oftcii unac- 
companied with pain, at least to any incoDvciutiat 




t» 



FiS- SO.* 



amooDt, but there in frecjuentlj- Aoino tendeninu when 
prenara is osed upon the swollen joint 



Morbid Anatomy of lihftimaloid Arthrilit. — The 
morbid uuUomy of tlio disoiuo hiw been cumfitlly 
ntudied by sane patli»l()gii«t8, but iwpocially by Dr. 
Adams, whose rasolts I will cndcnvour to givo in a 
mmll compAM 

The Bbrn-.iynoTia] struoturcA of the joints are much 
nitcn-d, tho dopmlM booomo much dutcndcd with 
synoviul fluid, and oxhihit nil tho tagn.s of chroniB 
influDtnation ; when the sjoiona ailerwards bccomM 

* Re. 13. Kuil of * hJr, vlth MdalM ftoJ diMortlDM ind«B(d bj 
ThaoDaUiil wtlffitia ; At «u niSiriaf bvm ■ obnoie iCMtiM of mm 
bip joint of » nmilkr utaiti 



»H 



KTrrrwATic ootrr. 



*bimrbod,tbooapsulMrinombranouUiftmucti thic 
Tlii) tnU-niiil Htntolum— u tbo nmnil lifi^nent in 
Itip-juiut, tbo tvudon of tho bioops in the ohouldor — 
boeono dwtroyed, and sro somctimce «ntirv'ly nMnorrd. 
When tlio diaonm has bc«D pnteDt in a joint for b 
loDf[ timo, the ortieular outilqM am sb^orbcd, mad in 
•omo very uld *taading omm mn (ho intdvurtuiiW 
oartittt^'M ; Uiu is oooHOOOalty srcii in tho knoo-joint. 
■Im in tlip wriiit. muI the lower juvr. From Uw 
MDotint of tho distmooa cwiaed by the fluid m tha 
mtly itM^m, tho diSHOot Uf^amctits bcoome cioogtitai, 
mkI being slow in rocOToriu; their uatural utate, Uw 
joints oro nmdtrcd mobile uid nore sabject to di»> 
loMtiaa. 

Fonign bodiM of rvtjixtg mm mi noniri itopet m 
sf ftvqtMat occumnc* ; mmeH nm then ars ottrtiW 
pnoaa, aouotimn brnty. mkI they ue eonaneted wid 
tho rtuM to u w of the j^iint by %aaieittiitia 
necnUr e i awee u w uv blurwisc conutkon. 

'Wbeti tbc uticiibu' iMrtilii^ haTC been < 
ranond. tbiv pbKo is «i{>t4ied by an msy-l 
■outat, rrtaarkaUe ix ita pelitih and hnnbaa ; 
•one joibt* this eaanitl eonn the oaliiv end at 
ben^ inelfaen it ocam in ftneVi m jietilim ■■ 

efl^wnMal «rf the 
pean to be ftHMd by At I 

{Mitly TOB away, waA a ^Malk aoaad fn^aad W 
AeMetMlaetinertbel 




HHEl'MATOID ARTHRITIS, 



Ml 



I 



In moat joints after the duid ha» become sbmrbcd 
a crepitus is felt on mnvenit^iit, from the rough tuiTftcui 
grating against each other. 

Mr. E. Canton, in hia moaograph and elttewhore, 
has called the attention of the profession to the fact 
that many of thuw nnatomicul changes, nsuall)' as- 
cribed by authors to the eiTect^ of old age, an< really 
the consequences of Theumntdd arthritu ; these re- 
marks apply moro purticulurly to the cliangi-s iii the 
osncuU of tho cars, causing imhuxt ; the diDtorlion 
of the juints of the feet, some diieaaei of the hip joint, 
and oiao the peculiar affection of tlio shoulder jnint, 
ompanied witli rupture of the bicipital tendoti, 
rimarily regarded aa difllocatioD of the' humerus 
upwards. 

Tho following is a description of the changes which 
wore exhibited by the hands of a mute patient w)io 
had suffered from this disease, and which much re- 
sembled the han<I depicted in fig. 31, the di«8octioa 
boing made, uud the nppettrancet described by itr. 
John Cooke, late House Surgeon to University OoUc^ 
Hospital. 

GfneraJ apptarance of Sands. — ^The anterior extre- 
mities of the metacarpal bones are broad and promi- 
nent and overhang tho pholangeo. To tltc touch th«y 
are nodular, aa if from fi number of small ttiberooa 
oat-growtlia. 

The phalanges are turned obliquely outwardt. 
The first row are placed ucurly at u right angle, 



U3 



KHEIIHATIC OOUT. 



conoot be cxtcnde*], but can Iw floxod to a somcwlial 
grcntcr extoiit. They appear as if dislncated on 
the jmbnar aspect of the metacarpal bonce. No 
gratb); la felt iu the nietocurpo-pbalangcal joints when 
tliQse boues arc moved in auy direction. 

Tho eecund row toe bent bockwftnls at vtrioua 
angles to tlie first ; they liare a diroctton more out- 
Wftrda than tlie fintt row, nud ftcem displaced oit to 
the dorsal surface of the latter hoiiee. Sodqc OYcr-lep 
the others, e.g., in right liand the bone of the fiooond 
finger over-laps that of the tliini, and the third that 
of the fuurUi. Tho little linger, however, doee not 
turn HO much outwards as the otlier, and in tho Ifift 
hand the bono of the tliird finger ovcr^laps that of tho 
fourth. All movement in the joints between this 
niid the next U lost. Tliey con, howorcr, bo mo' 
laterally, but no grating is felt. 

Tlie third row of bones follow th« some dircctioit 
as the last, and the joints between tlicsc and tbo 
second do not appear to be distiased. 

Only the mctaoarpo-phalangeal joint of en 
index finger is affected, and all the joints of 
thumbs aro perfectly nonnal. 

On removing the skin from tbo right hand, the 
more di.stortcd one, the extensor tendons of tho fingon 
arc seen, instead of ponnng over the metacarpo-phalan- 
gcal joiutit, to be puchod aside into tho spaces between 
them, apparently by tlic enlargement of the cuds of 
the Kkctacarpal bones, the tendons boing on the 
side of the fingers on which they afit Tho 






theifl 




KlltXUATdU) AKTIIItITE& 



513 



tendons appear to be ontract(<d, ibey ta-e displaced to 
tho outer side of botb the mrtacar]JO']>1ialaiiE;eal joints, 
and the joints between the first and seociiid phalangoe ; 
they then take their usual oouree with respect to the 
other joint. 



Mttaettrpo-pfialatiffeal ArlicaitUion. — The hiteral 
ligaments arc »trcteIiod ami lax ; the anterior liga- 
:it is thickened. a« also arc tho other Glroua strno- 
aroun<l, which help to form tlio capsule of tho 
joint. On opening tlie joint, not a vestige of a sjno* 
Tial mcnibrftne is wen, and the articular cartilages 
have disappeared, cKOCpt a very HOiall portion on each 
bone. Tho articular surfiioe of tho metacarpal bone 
has lost its rounded form ; the upper port is expanded 
and presents numeroua onall nodnlar projections, as 
uUo does the anterior portion. Laterally the bone 
is nlaorbod and luut a rough and wonn-cnten ap- 
pcaronoo. On the under piirt (palmar aspuot of the 
bane) and rather to the out«-r sidu is a small nuface, 
the upper third uf which i» covered with a layer nf 
mrtilagc the lower two-thinJd witli smooth compact 
bone ; this is tho only portion which hu the ap- 
peuronoo of a normal artieuliAr surihoe. The articular 
mrfiioe of tlie first phalanx is much shallower than 
natural, is roughened, and only small pieces of the 
cartilage lierc aiul there remain. 

A seotioD of the cartilage, from end of metacarpal 
bone, under the micro«cupe shows ]iatchcs in which 
the cells are Inst, nnd their place supplied by a con- 



S44 



RHEUklATEC OOUT. 



fused nasa of rety imperTectly formed fibres, decnsea- 
tingwith one another in oil direction}. These patches 
ore abruptly defined. The oells in the neighbour- 
hood are increased to about foor timee the stxe of 
thoae found in other part^ nf the oaiiilflge. They are 
more gHstening and their naoki are not visible. The 
cells at some distance are moch scattered, though 
somewhat grouped, hare no determined arrangement, 
and are embedded in a finely ^nular matrix. The 
oclU aro oval, angular, and elongutixl. The nucleos 
is mostly siogk-, sonii.-timc8 double ; imigular in xhape 
and sumi'timos oonUining nucleoli. Tlio gnmulee of 
the matrix bam somewhat n linear anuDgcmimt, 
giving tho tdoa of fibres. 

In the parts undergoing caloificntion it appears 
that tho earthy matter i» doiKutitod in tho orilitrged 
ccIIk, for on the addition of acetic acid, tho eiutby 
matter ia dissolved, leaving the cclU viublo. 



TXo Jrtkulatitm Mwem Fint and 8«etmd Phaiatu. 
— Tho ligaments, and all the filuxms stnuititras round, 
arc much thiokened. On openiog the joint tho arti- 
cohtr surfaces of the bones are found to bo entinity 
destroyed. The end of the first phalanx has beoa 
absurlod on the dorsal and palmar snifaoos, so that 
the bone, instead of being pulley-shaped, is wodge- 
Hbapcd ; both surfaces present numerous Uttlo proj«c- 
tions, which are oompoeed of fibrous tissue. Tlio ond 
of second phalanx is flattened ohU<iuely from tlio dorsal 
to the palmar i^urface, and covered n-ith tittlo projec- 



HHKrUATOtl) ARTIIRtTIR. 



MS 



tioiu. Betwocn tlio oppoeotl Kiirfuccs of tliceo bonm, 
and uniting them together, nro iiumoroui* smiill UindN, 
compoiicd qIao of wolt fonnod fibrou." tissue. The 
extremiticii of both boncA nro Rarroonded by a great 
number of little bony projections. 

The articulation between tbo second and third 
phalanx is perfectly healthy. 

The metucarpD-phidan^-al joints of tho iiidnc fingcn 
alone are diseased, tho other joints aro normal. 

AU tho articuIntioDS of tho thumbs ani perfectly 
h«altby. 



CaMet of RhmmaioM ArthrUw. — Rheumatoid 
arthritis is not unfreqneutly induced by the same 
causes which lead to aciitc rlipumntiem, moro espe- 
cially by cold, mouture, and dcpivssinf; af^-nci<«. It 
appears to be occosionutly exdtod by Lho oocurrcnMi 
of aciito rheumetinD, which «-oms in c«rtain ca.««« to 
cansc the joints to take on this particular form of 
action ; but an error is apt to ooour in our I'stimation 
of this tnllucnoc, inasmuch as it is pnbablo that 
rheumatoid arthritis, when it a«s»mes a more than 
usually severe charactor, is apt to stmulnte, and 
bo miiitokon for, rheumatic fever. I have knon-n 
sercra] cases exhibiting all tho chnmctors of rheu- 
matoid arthritis, n|^)ai«Dtly arising from Uiat form 
of rbuumatism which b connected witli urethral 
inflammatioD, and this was tho case with tho 
patient, the direction of whoso hands is descrilwd 
above. 




a a 



M« 



]iaiwiunc ooirr. 



Tlirii llio i(iiil(li>n prfldttction of debility will 
houdUv givii ri-Hi' ti) it I liUTe seen many oxsmplop, 
cspccinlly i» women afUir sproro bemorrhngc and 
rapid child-lx^ariu^. Rhotuiiatnid arthritis also ocean 
in young feinalcs labouriug under catnnictiial irrega- 
larity, but it apjioarB to me quostioDablc whether any 
q)ecial firvsn oait fairly b? laid upon tho uterine dis- 
turbiincc. Tho occurrenoo of tbo joint affection 
appciii-» to bo mure dupondcut upou tho acoumpsiij-ing 
depraved condition of tlie goncral systrm, and in 
numerous coses of tho discam I have found the cata- 
niooial function perfectly regular. In nmny instanoca^ 
huwerer, rheumatoid anhritia arises without any rvTr 
evident csuie, but generally in patients having nntu- 
rally a weak circulation, even thou^ ncoompanicd 
with fuln«.-ss of habit. 

Nature qf Rheiinuttoid Atihriiia.- — Our pontivc 
informatiou of tho intinute nature of this form of 
STthritU is exceedingly idight ; no proof has yet been 
stfurdod thut thiTU 18 ft morbid principle present in 
the blood, or thftt any alteration in its compnatioii han 
ensued ; in scvcrul intftaiiccs I have sought in vain 
for uric odd in tho blood Mium, and bare generally 
fouiui wi absence of any spoeifio ftllorntioa in the 
urine. Tho diaiigce in the iiifiunvd etructurce arc 
oomplet^'ly difTc-rcut from ihow whidi occur either in 
gout or rhcumttti^nl ; fur deposits uf urate of soda are 
noTcr produc^-d, but lu livu of this, ulceration of tho 
articular cartilages and ultorfttiotu in the oteeous 




BHKDMATOID ARTHRITIS. 



C«T 



tUeavs eome, which do iiot nx\i\t from truo gouty or 
rheumatic inflammation. 

It may he that the pMialiuritics of this form of 
diflMse dvpond rather on thL> tianii-it nSwlcd than tho 
pnaenc** of n morhid matter in thu fluiih ; in oth«r 
vords it may bu u form of ul<;cralt(m anil disintcgis- 
tioDt in these sltglitly rosonlar stnicturvis aritiing from 
dvGeiont iiutritioD. The whole sabjoct roquiros still 
farther st-aruhing inrcstigfttion. 

Dr. Fuller, who a]>p«ur8 to have a strong objection 
to tho use of the namo Rliinitnatoitl Arthritis, ncrer- 
tholcss huld« the same vion's as myself as to the 
nature of thi» iilfcetiuu, or nitbcr as to what the 
disoa«c is not : tliis will be seen from Uio following 
quotation from his work :— 

" The diaoose shotdd not he rcgunlod as of a hybrid 
oharoc(«r, or, in other word.*, niudu up in [inrt of 
rlteumutism, in part of gout. It is my fim conviotion 
that, ju«t as true rhetimnliNm and true ^Mi do both 
manifoet themsclvos at difTvrcnt periods of lifo in the 
same indirtdoal, so rheumalio gout may arif« in a 
pertoo who either has been, or may hereafter become, 
subject to true rheumatum or true gont, and that it 
has no conncctiGiD with either of tlicso diseases, boyoad 
that which atlaohes to it in virtue of its Ixnug a con- 
fitutional disorder, producing load Dtanife«tationa in 
Die j»iut«. Not ouly does annly»s of the blood, and 
of the fluid eifuMsl into tho joints tn them oams, wfaaa 
wcU markc<t ond distinctive, prove the absence of 
lithie acid, the poison of gout, as a cause of the aiti- 

■ > 1 



us 



EHEUMATIC GODT. 



i-iilnr inflnrnmntion and cnla^^enuint, but tb< 
ooturrcnce of any gouty deposit in tlie joints, in 
answering to my doscrijition of ihcumatio gout, ren- 
ders it niiinilost, even to a supcriioial otMnrvnr, that 
the pri'si'iicL! of truo gouty symptoms is ii Dtcro coin- 
citlence. and by no mQans cssculial to the cxist4.>DDe of 
the disoose. On tho other hand, analogy fumishvs 
strong grounds for the belief that the articular mt«- 
chief is not due to the presence of lactic acid, or 
whatever may bo the materies inorbi in true rliuuma- 
tisni, whilst the rapidity with which slnioturut di»- 
organiKatioa of the joints superroncs, even whoD Uie 
local action is apparently least acute, an<l whm tlio 
general symptoms urv certainly not indicjitive of 
febrile disturbance, is a further proof tliat it it OMen- 
tially didtiuct from truv rhL-umutimn, as typified in 
rhoumiilic fever, or in the ordinary chronic form of j 
the disensc. Intlcod, Iho circumstaucot under vrhioh ' 
rhoumntic gout nccuns the oxtniordiunry oWinacy of 
ita symptoms, tlio pf'culiur ullinktion iu tho structure 
of 'tho jointi^ which forms it^ most clmractorutMS 
feature, and tlic cIom of remedies hy wluch it b most 
Huct»>!ts fully combated, all seem to indicate a doae' 
oonuectiou with somo peculiar cunstilutioDol taint." 



Jrrfffular Fornu of Ittn-umaloiil Arth'iiii. — Occa- 
sionally wo find utlier parts than tlio joints nSeotvd 
with rheumatoiil orthritis, and tlie moist common 
nuufo^tnlion of the irregular forms mt' seen in tiii> 
cj'cs and oars. ^Mlea the eyes become implicatod, the 



EllEirMATOIJ) ARTHRITIS. 



CM 



diBcast! f>ciM>nil1y assumes the form of Hclorotitis, iritis, 
and conjuuotiWtu ; frequently thow uru votiibincd. I 
am uf opiniun Uiat mimy, porhnps the miiJDrity of tli« 
cases of ttiu so-L-Rllud rhctimntk! inSutniiuition of tli« 
oye, whou not fdtiiii'cl^-d with unithnil olfuctioo, aro 
of the uature uf Die dl^oa^ midcr ooilsidcration ; but 
it most bo rcRii>ia)>or(.'d thitt tlie tiivnuM of the vy« am 
often nffoctiM, both by true gou^ and rheumatic 
iDflammatioii. 

The following case is an illustratiou of rhouroatoid 
artliridH, butb of the joints and eye, but slight in 
charactor and rcudily amcaable to rcinvdial troatmctit: 

August, 18G2. — A Ituly, forty-MveD yoore of agct 
poatibly inheriting the affoction from hn ntntcrnal 
gnuidinothcr, camo tuidur my csro, having aufiinvd 
from th« fblloft*uig nnomatouH symptoms. About ti>n 
montlifl nnoo die hii<I itotiwd that one eye siidd4-aly 
became niTectod with nonets, uccumpniiied with some 
imtAtinn; this lasted altogether about fourdayv: since 
that timo, wttli tho oxooption of otiv tDturrul of six 
weeks, the same eyc*symptoiiu haro ratumod about 
each twenty-one days. 

Many mouths since— in fact, long boforo tho ore 
aflection — tlii^ hid}' had exjierieuocd pain in »unic of 
the &iger>joints, and at tlio time of her GnA visit, 
SOToral of the phalangeal aiticulatioDii were ooucwhat 
8W<^on and tender. Tho general health had usually 
been good, but of late she had flagged eomewbat, and 
ulicn tin«t seen tli6 cimdutioit was decidedly fccblo^ 
tlie pulso small and quick, tho oxtrciuitie» cold, uod 



GEO 



BHEDHATIC GOUT. 



abo vms easily tirpd by cxcitcmont. DoprowiDg cause^^ 
and oepocially damp, nppcarcd to onuso m incresso 
oil tlio syDiptonu. Under tlio influi-nce of imo and 
qiiininG, aud uftcra-ards of iron and cod liver oil, this 
patient soon bocnme greatly rulieved. the ej-o attacks 
very much Inw froquout, the cirDulation much im- 
proved, the lingcre decidedly better — iu fiuit, almost 
well, and tliis waa accompanied with a marked in- 
nease of flc^h. I feel little doubt, from the rapid 
prc^p^an already made, that tliis patient viU ere long 
be perfectly restored to health. 

Another and much more severe cafle occurred in a 
pAtieut under my care in the hospital. The following , 
is hor history : — 

Jntff, 186'2. — A woman, H. W., aged thirty-four, 
marriiKl, with two ohildrou ; none of her family havo 
suffered from gout or rheumatism. About tlireoj 
yosTS since she firet suffered &om pain and stiffiteat 
in the joints of the toes and ankles, which pnrvpnted 
hor going about her usual occupatioDs. A few weeks 
afterwards she noticed that her shoulders aud hands . 
were painful, and she has oontjnued to saffer more ' 
or lees in these diiferent joints. About ten montlu 
ago she appeared to hare had some inflammatoiy 
ufTcction of the lungs, and put herwlf uixler homco- 
pathio treatment ; she bo<:amo very weak, and during 
tfaut time her joints became much deformed and 
contracted ; her eyes also wero inSamed. and she 
almoai entirely lodA the sight of them. They after- 
wards improred greatly, bat she haa nerer secai 



RHRl'UATOID AnTIiniTIS. 



HI 







well since Three months ago tho pain in her limbs 
returned, and she wiut tin-a admitted into thu hospital. 
Her condition being as follows :— 

llio right wrist is much stiffened, nni] painful when 
attempted to be flcx«d or extended ; both Inuids much 
deformed, tho right more than the left ; the meta- 
cnrpo-pbaUngcal joints of the right hand nre Boxeil 
and incapable of extension beyond a few degrees, and 
e gruting sound \» heard on mori'tncnt. Several of 

i« phidiingciU joints arc nA>rc or leee fetiiTcncd. mmo 
pormiuiently fiexed, and conndcrablo grating is heard 
in the joints of the thumbs. Tho metacarpo-phalangeal 
joints of the left hand are flexed, and the phalangeal 
joints are but partiidly moveable. The left knee is 
considerably swollen, and some slight fluctiuitioQ is 
felt, but the chief port of the enlargement appears 
doe to the thidtening of tho tissues. There is much 
stifibess of the nedt, and tlie patient is in«apab]« of 
taming the bead many degrees ; tJicro is also tcnder- 
nees about the sorenth ocrrical iind firrt dona] 
Tertebne. The eye had remained in a chmnio con- 
dition fiboe the flrst attack; the vessels of tho aolo- 
rotio coat are dilated and turgid, giving a blood-rod 
appearance to the eyes; and the pnpils are vct^* large, 
and bnt little affoct«d by light; the putient can dis- 
oem objects, but tlic nsion is extremely indistinct. 



TrtatmfHt of Mftimatoid Arlhriliw. — It must be 
oonfesscd that in tliis department much is stiU to be 
uohierodi but at the same time great ^^ con eren 





ttUEUMATIC COUT. 

now 1)0 aooomplislicd l>y tho adoption of judic 
means. Wo must not utit^mpt to tront rlioumatdid 
artliriti) as gout, for oulcbicum u UsujJIv injurious, 
und a ejMUxt <lit;l fui from beneficial. Nor tnusl wni 
deul with it as with einiplo rhoamntixm, for the] 
alkolino troatment so semoi-ablo in llio latter is i 
sometimes, if muoh pnlongecl, pivjudicial iu tho { 
foniier diaoaHe. 

My own expcrienoo cnabUss mu to state that much I 
injury is frequently produced by injudidutu tn>at-] 
mont, ansing fmm a vroiig view of the natiirc of tlii* 
liittrtteo, and eepedslly from its being cuufuuudod 
either with true gout or rheumatism. 

Iu rheumatoid artlmtiB it u of the first importancu] 
to pay particular attention to the general health, and! 
for this purpose we must endeavour to giro tone tnj 
thv feysti-ui, and keep all the functitma of tho body taj 
hoidtliy action, but always by mild remedies. 

Iu the tirst place, we must pay attoutiou to tliol 
digestive organs, and if they are in any way weakened J 
endeavour to restore their tone by luttor stomachic 
either given alone, or oombinod with ainmonia or small ' 
({uantitiea of the mineral acids ; or if in it state u( 
irritation, we should try to soothe them by itlkalira 
other sedatives to the mucous membrane. l*hc con-i 
ditioQ of the IowcIh tthould bo attended bit, but 
drastic purgatives ordered. 

The functions of tlie nkin and kidncj'fi should uc 
be overlooked, but there is seldom anyraarke<l iilU'j 
tion either in the .itate of the skin or in tliv iiuutitity < 



RUKtraiATOlU illTHKITlS. 



CSS 



qualit)' of the urine, except in tlie aoute form of 
the disease, when & oertain amount of febrile di»- 
turbaoce tuny be preecnt, and the eluo may then 
become liot and drj-, and the urine scanty, Ligli- 
oolouiixl, giving nso tu u dopoEit of urates. 

If there bo utiy gn-ot dt-iicicncy in the puvrcr uf the 
circulntioD, and eq)ccially if nnttinia be prf^cnt, then 
the preparations of iron nsuaUy prove of cunitiderablo 
value: the choice of the preparation must be regulated 
by the peculiariticfl of tlie case ; if the habit ia relaxed, 
then the more astringent salts, as the sulplmtv or 
percltlorido ; if uiRtnua is prominent, llien the fer 
r^duit, the amm on iu' citrate of iron, or some similar 
compound, llie pcr^iveranoo for a long time in the 
use of ferruginous nalts i» often most useful, more 
especially when tlie [xitiont ie subJL-ct to coldness of 
the extnmitios, and otlier nigns uf a Linguid circu- 
lalioD. 

Utiininc and the vuioud galonical proparntioDS of 
obchona bark, given ulone or in conjunction with 
iron or other tonics, are aU» of mueh sorriee when 
thors is any cridence of debility either of the norrous 
or TMcular systems. 

Cod Uver oil in many cases is of striking value, 
■qpOquUy in weakened and spare hal>iUi, and if tliere 
is any undue waste going on in the body; I fre- 
queutly prescribe it at the same timo with tonics, 
or alteruate its use with them. 

Our great object throughout the treatment should 
be, as before observed, to maintain strength, aud m 



»4 



RHEt'lUTlC OOLT. 



want of tono mny depend on viirioiis eauses, 90 (he 
toDics must Us ndaptcd to individual ca.<»c& 

TlicK! wfo oortain ^lectal n.'ni«lios wliich mny often 
bo bonefieidly given, in«ro imrticulitrly with tlie vii>w 
of correcting the m»r1jid nctiun wf the joints. 

Guaiucum u occiudonnlly of great ossixtniicb whco 
there is much dcfioioncy in tint cxtroinc circulntion. It 
is bcflt given in tho form of tlio ummoniatcd tincture 
of tho K-^in, iintl this prepurution cnn gcncnilly be 
made to >it easily upun llio sliimneli by bring nibbnl 
up with mucilage, and combiiiod with thu compouDd 
tincture of cftrdamoms, or some olhiT aromntie. Now 
and then it im'tntcs the boweU ; thid can iiitmlly bo 
rc«tnti)ivd by the additioQ of a drop or so of tim-tiuc 
of opium. The compauud dconction of tsrmpariUa 
is now and then of dcrvicc, partly from improving the 
general health, and partly fWtm the guaiacum, scrpcQ- 
tary and mezoreon which it contains — drugs who^>_ 
actioQ is in many respects allied to that of guatacQia.J 
Iodine, either in the form of iodide of iron or iodide 
of potassium, may frequontly bo preeciibed with ad- 
Taotoge, and I have, vrithiu the ]ast two years, had 
u putii-nt under my care, suffering M■^'0^e1y from rhe^ 
mutoid artliritis in many joints both of tho npper 
and lower extremities, who, by porecveranee for somp 
months in the utte of the syrnp of this »alt. became 
quite reRtorcd to healtb. This oase was one wliicb 
threatened nt one time to eRu.<« complete crippling of 
many r^ the most important joints in the body. 

Arsenical preparatious sometimes appear to be of 



3 



nilElTJiUTOtD ABTIIIIITIS. 



tii 



■igDil enrkc, and for soreral yean I hare Wn iu 
the hiibtt of prescribing thi'm in rhcumiitoid iirtLritis. 
Anoaio lins iindoul>ti.illy h miuktxl actioo upon the 
gfcin, n fuet to wliicli cvory practiUoocr who has em- 
ployed it ill chronic cuttmooiui aifi-ctioDs cim War 
witn«fl8: it would iippcor olao Oxnt it cjccrtc an in- 
lluvnoo orcr the fibrous and othor imw» of low 
ritalit)', and acts upon them fts an altvmtive. In 
somv cases of this disoaso 1 hare seen marked benctit 
uiae from ita use, but in otbois arsoDio has fniled to 
alkmatc. though pushod to its full dose nod por- 
Horored iu for a long time. Muro commotily 1 Lnvo 
pTGwrilMxl the druf; iu the fonn of thv solution of 
arsonito of pota«h (Fowler's eolution), somdimc* ns 
arsenialc of soda, which, from some can-fully noted 
obserratioiis, I find to act less powerftdly upon the 
eyaem, as an irritant, than the same amount of the 
metal in the form of an arsenite. In pviag the pre- 
parations of oraciiic it i« udvi^ihlc to pay ntttMition to 
the state of the stomach in rt^fvnmoe to food, and to 
administer them soon atW a moal ; they are utnally 
fonnd to eauw less irritation to tlte mucous membrane 
andor such circumstsneos. In some cases of rlteu- 
natoad artliritis I bare had r^-aton to think that the 
arsenic has liad the effect of caimng great congestion, 
or eren an infliunmutor^' condition of the livt^r; in 
tlMW instances, boworer, the coincidenco betwevu thv 
liopatie affiration and the adminiatntioa of tLo anenio 
might {KiMibly have been oocidrntaL 
Nux routca and ibt nlkalutd strychnia are &ls> 



OH 



nHKouATio aoirr. 



oocasioiiiiUy oT vnltio, not from thoir rzorting nj 
specific acttoQ upon the duxHUO itself, but rnthor &tan 
tluiir iufluence upon the musolos, whidi ciltuii Im.'OOBU 
madi atrophied by long difioasc, auJ ihiut reodor tbo 
patient more complctdy cripi>lt<<l tlinu Ite vrodd 
othrrwLw l>c. Stnx'hniii and thv cxtniut of am 
vomicti ulso givD tuuu tu the digcitivc nnd OMimila- 
tinjf fuiiutioiu, nnd in tliia manner ofion do good. 
Many other mt'diL-ttica liavo troia time to time Ima 
propowd 08 romcdicft in tliis diaea»o, in fnct iiliuodt nil 
tbo dni^ of tho Phiumaoupoeia, 1)ut no sufliiaaDl 
oridcnco nf tlieir mluo luta been iulduc«d, nnd no 
ndnuttago would aoora« fn>m Uie diwiusion of ttuv 
modo of action. 

Hinonl vaton Itaro fn-quontly bcco rciiortMl t& 
in rheumatoid arthritis, but i havo knonTi grt-ot di«- 
•ppoiiitiuontt iind somriinin* mlirhicf, rcsult I'rotit thtv 
«aiploynii>nt, nrisiiig in many iuNlnncra (roin thoir 
iujiididouA iieliictinn, the truo character of tbo diMut 
being niUtnkt-n. If tlio more poworful vintcrs, as thuw 
of Vichy or Curlibitd, an- n^wrtcd to, tbo nytifim 
beoomen lowi'n.>d and Uie iLffvctioii inoreoard, and no 
good can bo olfordcd by audi treatment. Tlio waten 
most buio&ciid are thoHO whiuh t<-nd to n»(on> tht 
tone of tho Ny^tcm, moro cspocially Itio frrniginouN 
wat4!T8 of SeJiwallbaoh, Spa, and INtnbridgv ; thwe, 
Gombiiit-d with tho accampanying change of iiir uod 
frooduni from caru nnd biuiniws, vrill often bo attended 
with great advantugo, nnd airut tbo progross of tbu 
diBordfir. 



HHEUMATOID ARTHIEITIfl. . 



m 



The local tivutmcnt of rboumatoid artbritis must 
not bo overlooked. Tbu disease is inflammatory, 
tliout^li ]>(>culiitr in it< clutnicUrr, nnd in tho early 
stAgcft th« quostioa of (he pn^pricty of depletion 
naturally ariiws; in xomo tii.st(iiic(.vi ii few K<cchc8 
may !» n)>i>lied with adraiilage, and modcmto oountcr- 
irritation in ofWu of grr>at (utttico ; tliis is bent effoctod 
by painting the part with ntrong tincture of iodine, or 
by the u«) of a blister or oroton oil. Rest should be 
oujoincd at first, in the hope of aiding thereby the 
subsideuco of the iiiflamuiadon ; but when the fluid 
has been absorbed, and the alt«ratiou in tlie jointu 
adranccd so far as to forbid all idea of saving tbo 
mor« delicate t>tructures, then a moderato amount of 
movement is not only not injurious, but bonetidal, as 
it tends to pr^-vcnt a rigid state of the articulations. 
The amount of such movement must, in all cases, be 
regulated by Uie effects pruduted: it should always bo 
short of causing imy piiiu or tundomues lasting beyond 
tbo day in which it is ouiplo)'ud. 

Occauonally tbo use of planters is beneficial, by 
giving a certain amount nf tiupport to tbo joints, and 
abw by Itoeping up a slight counter>irritJition ; for this 
purpoM I sometimes employ the ammoniacuR), or tlio 
unmoiiiaoum and mercurial plaster, swmetimos the 
GalbRnuui, or even the soap or lead plaster if the 
skin b ver%' irritable. Great stress has been laid by 
sonic physieians upon the use of both local and 
general baths in tho treatment of this aHV'ction, but 
my own expericnw by no msuiB warrants mv to attri* 



L 



SH 



lamunc cotrr. 



buto to tliom tho vulno which tbcjr hnvo bvvti aflirui('<i 
by many to poaacaft. Wl)i'<n th« di.'Kw*o w still )>n>- 
•c'ot iit tlio sffltom— that is, wh«n fmth joinbi itro fium 
tinio to tunonttockixl — I Wlicrc Uint btithit fi1u&»hir> 
no power in arroDting it, or in altvrinf:; tho oondltiau 
of tlic hjttiit lc»<Iitig to its dt'Tclopmont ; hut, on tlw 
otlivr hand, 1 (nv\y ndtuit that baths nro ori4'n nuMt 
Tulunblo in comhattinf; tho flcqucliD of tho atToctioa ; 
la roetoring mobility to tho fltilTcDwl jtiints, nad in 
giTtng aapploncas to the muKlca. Fur thia purpcwe 
tolt or aca-vator baths or tho rnpour or Turkish balh 
may bo employed, and wunn doudicA, and KhitDipooing, 
uri< alM> of grwit lulritntago. Id tho aoDtu form of Hia 
■ffiaotwD I should place muc]i mora confidenoe io 
treatnMsnt dinvtod to tho nwlorhtioD of the oonstitii- 
tion to its healthy state, thou in any local n]»iilioataaa&. 

iHei ami lifffimtn. — In rlicoimatoid arihritis wo rnoit 
nut only aim at raatoring the diKntin) nod osicimilatitig 
AinotioDiv if dfrnngod, to n healthy Rtatc, hut wo moM 
likowLM liiVc cart' to supply the «ystom with uppith 
prialc Qourisbni(>Dt. I cunsidor it uf tlio utmoit 
importanoo throughout the whole ooumc of tlio diooaaa 
to support tho #yHt«in, and to allow tlio patient as 
nourlfiJiin^ n diet us ho iM cnpablo of proporly dii;<>i<tinK. 
If the appi-tiu- is not very good, then food abuuld bo 
gireo moru frf<|U('ntly. Moat ohoold form a oun- 
sidoraUe portion of the diet, and when it cannot bv 
taken as ordinarily cookitl, it is of advonlagu bt 
hftTe it in tho form of potted m<.-»l, taking coro that 




KIIKCUATOII) AUTIIKITIS. 



iKt 



tlie wboto of the juioc; of the meat bo introduocd. Any 
IcumI of antmul food wHioh is found to be cosily 
lussimtluh^^ muy bo adiiiiDiittcTGd. 

I ofluii tiiid thnt patic-nbt Huflcring from this disoasv 
an pr<)hil>itc<l from ttkititt: miiU liquors but I have 
OTory reason to know that when the oHoction is one 
of true Olid uncomplicated rheumatoid arthritic, it 
IB not aggravated by them ; iii fact, wlunt they 
IgrM with tlie stomach, they Hften enable the patient 
to take more solid food, and at the same time cauM 
its moro eiuy aasimilatioii. The same may be said of 
wines. Hy nd« is to giro suffident of these aloohobc 
boreruges to support the tone of the wliolo system, 
but not suiBcient to exoito the ciroulation, and thereby 
produce subgcqtumt reaction. 

It in of tlio utmost importanco that the subjects of 
rhoumnteid arthritus should havo ns much fresh air 
as possible, and a cluinge of air from time te time ia 
often dusirnblc ; if the Htato of the limbs be such 
as to prevent walking, or horw cxcrt-ise, carriage 
airing!! nliould bo rc.'iiorted to. Hio proper vootik' 
tion and tomporaturo of the nttiiig and slcopiDg 
apartments should not bo tout sight of. 

Lastly, the clotUitig should bo wsim, but not suffi- 
cient to overheat tlie patient, or cmho too much per- 
ipirntioa ; t» a rule, Hanoel should be worn next tlw 
dcin. 

Diagmm <^ Rht^maloid ArihritU, — Rheumatoid 
arthritis, or the so-called rheumatic gout, may be dis- 



B<0 



RIIKL'MATIC CODT. 



m 



lingutshed boUi from gout and rheiunatisni hj- maor 
ehaiaoterisde signs. Haygarth, who, as beinrc stjit«d, 
terma the disease nodosity of the joints, says : " Thv 
nodes appear most nearly to resemble gout ; both nf 
them aro attended with pain and swelling of tbe 
joints, but they differ esscutinlly in many distiiigw<^ 
ablo circumi-tancci«. In goul, tho ekin and othtf 
intogumcnts are ^■ncniUy inflninod, with pain, whieb 
is very ocuto, soreness t«i the toucli. rodnesB ani 
swelling of the mft parts, but in no rKpects liko tlic 
hardness of bone. The gout attacks the patient m 
parox\'«n)S of n few days, weeks or months, and lias 
compli-tt> intenniKsioiis. at first for years, hut after* 
wards for shorter periods. The gout attacks mm 
much more frequently than women. There is one 
distressful circunutona; whieh distin^ishes this difr- 
(odfir; it has no interrniiwion, and l>ut slight remissioi^y 
for during tho romaindcr of the patient's life the Qo4^| 
gradually eidargo. impeding more and more tisfi 
motion of the limb; tho malady sproads to otluv 
joints, without learing or producing any allcriation in 
those which had been previously nttaokcd." 

To this disigiiosis of Haygarth, which is for the 
most part eonwit, nitiny additional points of difference 
might be mvntionod. Thus as regards the seat of the 
affection at it« fii^t invasion, gout attacking the ball 
of tho great too, the other disease any joint io<liiu 
criminately ; the one often leading to the formation 
of chalk stones, the other nerer so doing : tlie 
charaeter of the blood in the two affections is likewise 



BHBOIUTOID ABTHBina 



Sfll 



^ 



^ 



widely different, u arc also the pathological ohanges 
produced iu the injured joints. 

Between rheumutixin and this foim of arthritis 
there is generally n gmit nMcmbUocfl, but still 
many diagnostio phcnomciin con bo detected, at wQl 
be obacrred in the appciid<Kl tabular airangeinent 
(p. £72) which I have drawn np in order to show at 
« glance the characteristic difiercncffi of gout, rhea- 
matism, and rheumatnid arthritis. 

^e following are a few caws selected from a largo 
number contained in my case books, illnstrative of tha 
dilTcrent furms of rheumatoid arthritis, and tjf the 
pcculiuritiee exhibited by the disease in different 
subjvctM. 

Casb I.->-Slight rheumatoid arthritis in a yoong 
lady, quickly relieved and cured by a tonic reator a t i Te 
trcAtnusnt 

A young lady about serenteen years of ago, Babjcot 
to cold i<xtrt<mities and other signs of a lan^d circu- 
latioUf somo year or ko sinct' oxpi-ritiKxd pikiii. tendcr- 
ueas, and swolling of Uto anklon. At lir<t t]ic«t were 
th« only joints aficotod, but after >>i:ime months the 
fiDgns and wristf bocuna tmpUcatc<l. and were so on 
ber first visit ; tiw phalangeal joints were tender, and 
aleo u little enlarged ; ramo of the toce wore likowii<« 
painful, wpMially tli« great tocH. The toogue was 
red and mmcwhat glassed, but there was no thirst; 
the boweU were regular; the skin acted fredy. Pulse 
small, 96 (probably excited). The mucous membranes 
were distiactly pole, and a loud ronoos mnnnur coaUl 



• 



M3 



ttHEUlUTlC OOPT. 



bo hcanl in Uio ncclt ; tho ciituiuoQia were regular; 
sbo had became thinocr of late. Wciithcr appdn4 
to liATO wuno influcDCft upon tbodiMMflu, unci ohc alMxi 
thnl «ho te\t irofM when it wu cold. Under a ttcsl- 
Dunit (lirootvd to fortify tliu system, consiatuig of t 
oombiuatioii of nilpluitc of iron and qiuninc, and die 
npplicutiun of n modrrntvly etroii); tiiivturc of iodtau 
to the joinU, thitt |«ti«at rapidly improred, and is 
DOW iiuito Vi-c1l. 

Caxk 2.— Rbouinntoid artlmtiv, probably arinn; 
fiam prolonged fhtiguo and great moatal anxiet>'. 

A liuly, fifty yrara of age, enino under my care witk 
tho fnllomng symptoms. Her general health vti 
formerly pretty good, but she bod never boetu strong 
Tho diwafto onder which sho wan eufTvring bad cicd- 
menood nitlier mora than four years ago, at flnt b 
the hands and fit-t. It iippcarod from her bu<tory that 
Bhe had portly bi'forc this nndergono much fattguc, 
and giviit itiid prolonged mental nitxiety. Frao 
hor own nocount 9ho had been treated b}' {Mnx'rTuUjr 
dopnvtfing agents, among which were eotcbiciuii and 
the iodides, also by frequent haths, whiob, oho aaserb^ 
mode her moob worse. At present she expericacM 
pain in almost every part of the body, whidi is 
tncroaied when in bed. The knees and aoklcs are 
much svoUeo and etiS, and tho shoulders nro im- 
plicated ; many of the fingers are contracted and boat) 
the thumb joints rtp tondcr, and there is much Kitting 
felt and heard vahea thoy are morod ; the wrixta ore 
alao swollen and painful, and scorooly allow of any 



BHEUM-lTOrD AirrnRiTis. 



H3 



inotioo. Added to all tbcee discomforts, Uic patient 
iH unable to more her neck with anj-tbing Mk« frocdom. 

Till) catoincnia a>ased about seven years ag;o. 

OAaE 3. — Rlicunutoid artliritis, probably aScctiiig 
tbo laryngeal structures, lui well oa the joints. 

A lady, iibout fifty-right ytara of ago, when sho 
fint consultod tnc, hud «ifl»rod from pain in her IiniU 
for twelve or fourteen ycara, in fact soon after licr 
last e^iifiiiument : several of the snuiU Joints of tho 
luuids wcro stiffened, Mmo a little swollen ; the last 
phalaiigeiU joints of niany of her fiiigi-ra w«i« cnloi^nod, 
so Bfi to give the peculiar nodose appenranoc ; tho hips 
were di.-^inotly uffuct^.'d and stilTonod. Bosidca tliOW 
sjmptoms, this lady ^uffi-rcd &oin hur nock, which had 
beon gmdnolly getting stiff fur about four years, but only 
very inconveniently so for the last eight or nine months; 
for some tune there bad boon an uuoomfortublo stato of 
the throat, causing a littlo hoarscooss, and some dry 
Mmgh witli a pridcingnrmiiatioti, but there was no t«nder> 
ness of tlie trachea or lannix, and no pulmonary affection 
could bo detected either by percussion or auMiultatioo. 

I have seen other cases of laryngeal disease in 
iiubjcctA of rheumatoid arthritis, and am inclined to 
think that the Htructuros of the larynx are liable to 
be affected in the same manner as those of the joints ; 
in otlior words, (bat tho lar}Tiz may itaclf suffer from 
rheumatoid arthritis. 

Cask 4. — Ubounnitoid arthritis occurring in an old 
gentleman in hU iicventy-nintli year. 

A gentleman, seventj'-ninB years of ago, pravtonslj 

00 S 



tet 



SHECJIATIC GOIT. 



enjaj-ing good hcolUi, liad ftbmit six montlu bofim 
ooming under my ct>rc Mt paiDS in the joints cf 
the upper extTomitie!) ; the shoulden and clbon 
iroFC Rnt lUTcvtcd, ofterwnrds the mists end hands; 
when I nav hiin, the hitiids were pginiiil, tliv wiiste 
stiffened, th« flngnrs swollen, and tlto first row of 
phal&n^al joints mocb more rigid than the rest 
The logs and feet wbto scarcely unplicatcd ; th« pain 
appeared to t>o very severe, and increased at night so 
■s to prevent sleep ; the tongue was somcrwhat furred, 
tho hftirt's action nxak luid iutcrmittcnt, and them 
was much irritability of tlio lludJur from prostatie 
diaoBft& Under the iiiltucuce of n toaic plim of treat* 
ment, coDsiitting at first of biirk and aiomnnia. and 
afterwardi) of small doses of reduced imn, the joints 
became muoh less svoUen end Ktiff, the pain grvatljr 
dimini.'Oied, and the sleep improved, in fiict, the pro* 
gross of the joint affection appeared to he Btoii[ieJ, and 
the alterations already induced in the articnlar stmo- 
tnres oontdderably ameliorated. 

I have seen several other patients saffcring from 
rheumatoid arthritis, in whom the disease first 
appeared when tlicy wen considerably advnncvd in 
life, that is firom ^^ years of age and upwnnhi: in 
such cnsix it seldom orinees so great a tendency to 
run a rapid course as in younger subjects, bat slill it 
may bo acute in its character. 

Cask 6. — Ithcumutoid arthritis coming on at the 
time of the cessation of the catamenia, and much 
improved by titatmeot. 




BHEUMATOll) AFTnBITIS. 



003 



I 



I 



A lady, itfty-tvo years of age, having do heredi- 
tary predisposition to any joint affection, nmrriod, 
and has bad three children. The oatomonia. whidi 
were alwoys vor>' scanty indctJ, and ocoiirnog at 
prolongud iiitcrvaU, coomhI about duvon years sineo. 
The joint iillcctiun appc-ars to hare bees ootioed 
about ttiti tiiQfi of lIiU ccmttion, and after expasuro to 
oold and damp, ftrst in the shouldcn, wrifits, and 
hands, nftonrards in the knees and ankles. During 
tlio lu«t livo j-oors she had become much worse, and 
oepecially witliin a few months of her consulting me: 
all the joints whieh had been implicated from tha 
first attack, hod remained so in a greater or leas 
degrea 

Thi^ patient was itout, hat the complexion and 
muoom mombnuies were pale, and the muscl&s tbbby; 
ibo wa« sattject to cold extremities ; the pubc was 
weak and <iiiiok ; at timca she felt faint ; mfiiDRd from 
atonio dyspi^Ba and constipation. The ksMw were 
gieatly swolton, gratii^; mnch on moremmt, the 
wruits very stifr, almost anchylosod. and many of the 
other jointa more or less aifcoted. By troatmenti 
directed to the improTcmout of the gcnoral health, a 
marked alteration ensued in the state of this patient ; 
her colour improred, the joists became Hmallcr and 
more flexible, especially the wrists, which were nt firsc 
80 stiffened, and she was enabled to walk somo Uttlo 
distance with cumparatlTO ease. The trcatmi-iit con- 
sisted iu the uno of iron and qniniDu, with the occa- 
sional adminiitjation of the arsenical solution ; aad 



ns 



ItUEUUATrO OOCT. 



flio tpplioation to the joinU either oFtho ammoniacuiB 
and nwrcuriol plaster, or of tbo strong dncturc of 
iodine, bat not so as to produce any severe injury to 
the skin. 

Case 6. — Rheumatoid arthritis coming on at tho 
cessation of the catamenia, tuuob impruvL-U by treat- 
ment. 

This Udy was Sfty-three yean of ago, and hor his- 
tory and symptoms were as follows. No 1icrcdi(ur>- pt»- 
dispoeitiOD to goat or rhcuniulism from hiT {Min*nt8, 
but one nunt had suficrod from some low form of 
joint diM-asc, and another from au afTectiun of the 
eye, termed rhuumatic. Her general healUi hod been 
moderately good; tho cutamonia had ceased about 
four yean isinoc* at which time tlio joint iifFoctioo 
fiomo on. At first tho joints of tho hands Locama 
swollen, thu knees were afterwards iiapLicatod, then 
the ankles, elbows, and so on. At the timo of her 
first visit, thu knees wore niuoh swollen, nus^sbapod* 
sod very stiff ; on uttcmptiDg to move tho joint*, a 
loud uraciklin^ or grating was heard ; tho aunc «ondi< 
tion was found in the ankles and elbows, and tho 
wrists and hands were stitf and altered in shape. 
There was also some stiilhess about the nock, and 
inability to open tho mouth wide ^m the arlicula- 
tions of thv lon'cr jaw being implicated. Tbo extre- 
mities were very liable to be cold, pulse weak and quick, 
mucous membranes pale and somewhat anainuated. 

By tbo aid of fer riduit, continued for a long time, 
together with tlie use, at different times, of other tonios, 



J 



RIIECMATOID .UtTUBITIi 



MT 



BS bitrlc, cod-liv«r oil, aod Hmull Aoh-s of arsonio, and 

the occii-tiutial appltuutioii of strong tincture of iodino 

in streaks upon the joints, tLi^t putiL-nt, fnim being 

completely crippled, vnat able to diotv iibout, nud vrus 

gtiU gaining power wLen last seen in consultation. 

■ CiBE 7. — Very severe rLeumatoid arthritis, appa- 

H rently caused by severe cold iind dump. 

^^ A gcnllcmun, tliirty-soven yours of ngo, ha\in{; no 

^H^mlitar>' prcd)H[)0(«itioD t<i gout or rhouninti»m, gnvo 

the following nccouut of hi.* eiiso. About eleven years 

_ since, aftvr a wet journey, ho slept in u dump bed, 

y nnd oil the following morning o<»nplnin('<I of pain uod 

tcndcnuvH in different parts of the body. In about u 

tibitniglit or tixrve woclcs tho symptoms subsided, und 
ho WW able to return home. ProviouA to tlio journey 
his licolth had boon pretty good. Shortly after his 
return tlio articulur affvctioii cume od, joint after joint 
becoming painful and tender, unthout nny consider^ 
ablfl HVolling, but leanng cacli joint in on almoat 
uwhylosod condition. IrVhcn this patient connulted nio, 
bis general health was good, but tJie state of the joints 
lerriblo. Most of the fingers were completely stiffenc^l 
and distorted, likewiitt the wrists ; the left knee was 
semiflexed, incnpublv of being extended, and only 
aUe to bo bent a few degreo« ; tho right hip j<Hnt 
and left elbuw were i^uitc stiff; the node. aW, was 
aeoRcly moveable, and many of the other joints more 
or low aSected. He appeared to liave been treated 
at first with colobioum, iodide of potassium, and other 
rcmcdiet, but without any improrcmcol. A# tha 




rz 




CHEtrUATIC noUT. 

gBoeral hoolU) waa good at Qm tinui of his 
mc, and M the progrcflsive tendency of the joint 
tioii appeared to have stop|>ed, and the articalatioiu 
vhicb hud been attacki^ wpre UTeporably injure 
of oouno little nr nothing ronuiiucd to bo done 
mfldieiiud ticatnicnt. 

Case 8.— Bheomatoid arthrittB, Uliutralivfi of 
inflnenoe of freqnent ehildhirth ukI bemorrhogu npi 
its dvrdopmunt. 

A huljr, Bgwl fort>--«n-eti, ooonlted mo, sofimi 
trom riiL'umstoid urthritiii, and gare the foUo' 
■ocouut of licr ctiac. 

Her fiithor and mother Itnd both jiuflorcd from jo: 
diaoQM. 8ho hcrsolf hod had oxtocn eluldroo, indi 
ing nrcra] misMniogQe. TheoMostwastn-unty-sevei 
aud the youngest throo yean of ago. During tl 
Laat twenty yean sliu had been vei7 wcnkiy, frum tb 
froquiiit lulioont and ntti'iulnnt liemoirhnge. 

About a year ago tba had tlntt . noticed pain 
Bwdling of the hands and wruta, and to «nmc extei 
of the dbnws ; sinoo which time many of tfao join 
botli of the upiicr and lower oxtremitiva have bM 
attacked, and after a joint has onoe hcon affeoted* 
hat alvrays remainod in an injured condition. 

At the tine of bor Arst viat, tho KhtniMcra, vriat 
bands, knoe«, and onklw wne twoUcD and painfti] 
tlte neck vas likewiso mud) attflaoed from tho n 
ocrrieal vertebro boing implicated^ The pain 
considerably inorosfscd after t)ie piitieut had been 
bod for an hour or so, and ujiou waking slio waa 




KUEUMATfUD ARTHBITia 



sea 



stiff OS to bo unablo to moTO. Her gmeral health 
was not good ; the pulse waa weak, 73 ; tiie com- 
plexion pale and sallow ; the $)dn rather ilry ; tho 
tongue Airred, and the appetite bad. She had aUo of 
late lost mooh flesh. The catumnua hud bivn absent 
for about eight months, uud invgular und scant}' for 
three yeai«. 

I have had screral other caws under my e»n, in 
which rheumatoid arthritic has borti rapidly developed, 
aAor ooaridombto loos of blood from frequent mu- 
evrinKn or from numerous labours occurring witliin 
a sliort period. 

Oass 9. — Rheumatoid arthritis, apparently induced 
by severe mental depresaiou. 

A ludjr, thirty yeans ot age, consulted me with the 
foUowing ^rmptoms. Her h«altli had been good, hut 
about ten years since ake had had a severe illnc#8, 
followed by swt^ing of the body, legs sod tiu», irhJoh 
lasted about two montlu, and was termed dropsy. 
About three years ago, having previously soffined {ma 
itry eovero mental depresion, the articular affectioa 
oppcorvd, liist in the phnlangedJ joints of the fingers and 
thumbs, then iu the elbows and shonldere, and after- 
words in tlie kuGCs and feet. The r^ht olbow has bceo 
aqpeoinUy injured, and is now partially onehyloticd, 
the movements of flexion and extension being very 
limited. Her gciienit hiwlth is uow (iti from good, 
there is marked ouiumia ; tlie catamcnia too frequent, 
the pulse small, and the appetite bod; she has alau 
become much thiuner of Ute. 



570 



UHEUMATIC COCT. 



Under a tonic trcntiiicnt, consisting of iron, qaininr, 
and ood'Iiver oil, this patient impntved maoh in 
(;i^neral Iioaltb, but tlif cll^owii remained vcrj' etitt. 
The progress of tlie nriicultir nffection, however, hu 
been arrested. 

Oabb 10. — Rheumatoid arthritis, arising wiUiout 
Mjy ftpparcnt cause, but proceded by marked dc- 
nngcment of tlic f^-neral health. 

A lady, tliirty-fivo years of age, came under my 
care, eufforing from the fuUoTiring symptoma: — 

No hereditary tcuiloney to any joint affection 
bo diiicovercd, her health had usually been tolorftU] 
good, but for fume little time before tho commonco- 
ment of Uic joint affoctiou, she hod been getting 
d«o)dcdJy ^-eaker. 

About two nitmths bofore «ho con8ii]t«d me,dielLad 
noticed pckin in tho rij>ht ankle, atti'ndcd with sotnal 
swelling ; the knecis soon became stiff, «ul then tho 
trft ankle ; soon aAor this the smaller joints of the 
hands, and the elbow's were implicuti.-d. From tho . 
lirKt Dppcaranco of thd di8i>a«e, the joint affoctio 
bad norer left her, although for a time there ms 
a alight improvement ; in fact, the ooorso of tha < 
discaee has been uniformly progre&aiTe, at 
joint after joint, and always leaving them mora or 
leas damagt>d. 

"When first seen this patient was thin, folt vcay 
wc-ak, and wax easily fatigued ; pulse small and 
quick ; extremities cold ; CMmpIcxion pole, and tongoo 
deuD, a little ghwi imd appetite Imd; ntomeuia 



BKETMATOID ABTHRITia 



m 



4i^3ar. Many of the jomts of the iingon wore 
enIaT|[od, U>iidor, nod stiff, as likewise Uio wrinte and 
«lbow!t; the Dock wiu iilso itomewlint rigid. No 
narked iiiercnso of piun vnw produced ly tlic wiirmth 
of the hvd, but llio jt)inti( woro iilwuys vt-ry stiff iu the 
morning. 

This piitiont improrod much under the use of 
cod-liver oil, cinctioiiii bark, nnd xniiill doses of tbo 
iirMMiical siilution, together with the uppliciitioo of a 
Htrung tincture of iodine to thv joints, which relieved 
the lucitl Kymptous. Sh« i» gtil] under trcutQictit. 

MueeUttiuiotu Cow*. — Many cases of rlipiunitoid 
artliritiH havd come under my nutio.- in vliicfa the 
•ffoction was confined ti) the phulungcul joints of tlio 
fingers, sometimes to the sccnid row ur cxtn-ma joints. 
In somo instances I Iiuvo seen one or two mumbt'rs of 
A fimiily ba\'ing tliis fomi of the disoiuOi and another 
in whieli thu malady has iidvoncod much further, and 
implicut«d many of the iLrticulatiinis both of tho 
uppor nnd lower extremiticis. In by for the greater 
numbur of ca«os in which the diN-aa? has Ix-en ED 
limited in its dmnictcr, tliu pntiunbi linvo beoQ 
females, and it has asually occuttuI nAcr the miildlo 
period of lifcv somvtiincw in old age. The Udy whose 
hand is rqmssonted at page f>'-i&, bos two MsU'rs, both 
baring the nodular stato of (lio fin<,t'n iu a Tell 
marked dcgn-v, but no other joints affevti'd. 




Ifiiluofd by 



^" v.*. period!.,, I.""""'- 

bV. t"::^. '"-i"i: A.uci, ^ „ 






CHAPTER XVI. 



I 



ORATSL Attn ciunua— wijitiCit asd um»4Go— siran m» 
UiiR iK» THi (*c(>>iu>r ooanqoiMB or — utaiutT or ooott 
rATitio* TO BH irrmui bt uii>— PMrnTUcno i»jkT>i*r 
Of aocT— ni»aBo«i* or minuToiD i>niKiit»— rtMvjiii or 
oect. 

- 

TirBBK sre certain discasM which appMT to bo 
doR'ly coDttocU'd with a ^uly ttatc vf tho sytbim, 
or the ao-callcd gouty difltlieas; unonf; thuse we 
may mention, more partioolarly, certain forms ot 
grave) and calculus, kidne)' disease, and likewise 
lurabaga and ticiatica. On tho peculiarities that iheoe 
afibctions exhibit when they occur in tho gouty bahit 
wo shall dwell for a ehurt time. 

G^riHv^ and Caie¥iu4. — An we have shown that it u 
Mwntial that uric acid should be in abnormal quan- 
titiee in the blood in order that gout sboold be pro 
ducrd, althou;:;h something more is ncccssarj' to cause 
«n iuBanunittury nttadc, it GjUowk 6x>m this that the 
gouty and (so-called) urie acid diutlicas miut nooea* 
sarily bo the mno, and wo should tuiturally expect to 
lind gouty |)ati«nti freqaenUy cxbibitiDg symptoms 
tvsultug frem tbo pnacnoe of swdi diathesis, mure 



fi74 



Corr AKD ttUEirMATIC GOtTT. 



eipecialljr in the passage of urie and, or uratos in llic 
fona of tbo vnrioiu crystttUIno and amoqihous aandf 
and oalculi ; tlio voiding of ario sand hy gattj 
patients, during mmc pvnnd of lifi), is oxoeedin^ 
common and the furmation of calcoli hy no mmot 
tm&equL-nt ; its a rule, wlicn in carl}' tife gravel and 
caluuli are formiL'd, in nftor yours goat devclopes itself 
in tliv same- indii-idiml. It will W rvmomburcd tluit 
Sydrahiun himself labuurt-d uad«r tbo combined 
niiiTi>ncs of gout niid calculus and in cvxplsnatiou of 
the co-oxistcnco of tlio two diseases, r«Quirk« : " Gout 
produces calculus in tlio kidnoys, which may ariw 
either from tin- patient Ij-ing so long on tiis back, or 
frgm the secreting organs liaring so lung omitted thor 
functions, or tho culculua iteclf may bo a part sn4 
paroel of the morbific matter. Be this as it nuf, 
the patient in frequently at a loss to know if the 
stone or gout be tbo worst disease." Hoigagni Uko> 
wise conflidered that calculus of the kidiwys was oftnt 
joined with gout, and ho relates an ioBtanco in which 
botli kidneys were distended from tho presence of soch 
ooncretions. Sir C. Bcudamore did not think that 
there existed much connection between goat and 
calculus, remarking, that in fi\-o hundred patients, 
only five wcTo so iifflicU.-d ; still, he qualified his 
statement by tuiying that in many casee he had soea 
coiicTctioDs discbiLTg^ from the urethra of oonsidoiw 
able size. 

Sir It. Btaekmore relates that Dr. Wallls attcndMl 
the celebrated Dr. Hammonii, who, when ho was 




4 



DISUISES IS CONNECTION WITH. 



S7S 



Dd of the stoiw, was Bliaq)Iy attacked with gout, 
and when fiy>ed from gout vtob grievously, and at laat 
fatally, assaulted by tlie stone. 

I have mot with numerous instances of the occur- 
rence of gout and calculus in the same indindual, 
bat of few in which they wore proscnt at the samo 
time. lu tliese cased, the calculi are uxually com- 
])osed of uric acid or urate of ammonia, but it in not 
uncommon to find oxalate of lime, either by itself or 
altcniating with luatcs. Oxalate of lime la likewise 
frequently preM'iit iu the urtue of gouty subjeota in 
the different forms represented in Plate TI., fig. 8, 
a, &, e. Such an occurrence is not to be woodered at, 
as uric acid is readily decomposed into oxalic acid, 
and the latter add, as I hare prorod by repeated 
obwrratiMii, is always preoait in blood which cnn* 
toioB BD abnormal nmuuDt of the unitoi. Uzalie 
acid is al»o oapalilo of being obtained from the socre- 
tioo of tlu) skin of th(> same patients. 

Lnmlago ami Sciatica in connedioH vilA thr Oonlg 
ZMJuni'i. — Lumbago and, more etipecully, sciatioa 
are of such frequent oocunt- iioo in connection with 
ike gouty diathesis, tliat it is as well to qieak of 
thciD sppnratvly, although tbey might have been 
included in the chapter on the irregular forms of 
gout. It is of the highest importanoe clearly to 
moke out the correct diagnosis of sciatica, as tlio 
treotmont adopted for one form may hare little effect 
ID altoviating ai»>th«r variety; nay, it may orva 
cauao an increaM of tho ijiaptoBU. To make a 



B7i 



OODT AND BUBITIUTIC OOOT. 



ooTToct <liiigDoait in moh cnaw it 'u noaeaaaxy to : 
tain many ))cHnta in tlio bistoiy of iho palii 
tbo umuuiit of hon.'iliUry prDdispositioiit tbo 
of life, ettpomll/ vritli regard to the character </ ' 
oloohulic bi'Torogi' thu patient hu bxx-n 
to takv. Our spaae will cot allow w to <^tcr 
lengUi into thu ral})i<et, Init wv will giro thv foUo^ 
ing o&M ■» LUiuttnitivc of tbo tUvcLiun when in 
neetMo with tho gouly (Uathcais : — 

A gmtleman. forty ye«« of age, rcoontly 
ttaieT my care sufiering fixim sciatica, which, whc 
originating or not firom gout, wud cvidoQtIy kept 
by the pn>ecii«e of the diathesis. Ilia futluT 
brothor had soffored innn gout, and he- hiul liii 
exporieneed two or three attacks iu tho )mU1 uf 
oroth«rgTrattoeand ID nucanklo; tho first 
aboot six yean since, the last acron or oi^ht iDonlha i 
At tho time when tJio gout wa» lant npou him, be 
sdzi-d with seiatica on tlio left nd«, bat ho ihinb 
that vxposuro to cold might haru bivu tho mat 
oaoee ; the pain was felt chiofly in 11il< hip tiod oal 
aide of tbo log and insU'p, but not much in tho 
During the hut aoTm mnnths the aoiatica 
tinuul, sometimiM a little bott«r. at other timaa ntid 
woivG ; tlie pain* nr« inerooaod by standing or 
ing, but not notably influenced by ult^'rutiona 
t(?mpeiaturo. Tho urine in tho early atages wa» : 
and thick, but in now jialo-oolourcd and ckiar : 
(M.-vonty*two ; no iuitvaeed ht'at of skin. 

This pativnt hud been tnotul fw aumo tit 





DISEASES IK COiraBCnOS ■WITH. 



m 



inuny of tb« ordicar)* remedies for Kctftticn, but tiw 
diet hiul not l>ecn attended to, uor had the presenco 
uf the gotity diathesis been taken into account ; 
when placed loidcr a proper reginien, wine and malt 
liquors being ]>ruscnl>c<l, nnd tlie ordinary- medioiiial 
tieatmotit of gout Ado}>tod, 1r- rnpidlj' lost bis p&tnfiil 
affection iiud was restored to bvaltlt. 

Ax t])i> IddDcys nro prone to become ooiitroctod id 
ohronic forma of tliia diacaae and therchy toxv tnocli 
of tlieir t'xordory povrvr, it follows tliat the a«ondaiy 
disutxlL'Ts (>oinini>iily resulting from such a cause mnst 
DeiM>seairily be found among tht> sequela? of goat. One 
of the mo^t frequent of these is irdema, either con- 
fiued to t]io logs or KometimeB of n moro general kind ; 
effosionii into the caritioe uc likowiM? found, consti- 
tutiiig ascitex, bydrotborax or hydropcricardium ; in 
wme ca.<i«!i depending on a low form of inflainmatury 
iiction of the ktouk membranes, bat in others simply 
on piksivv o4rui<ion. Kpilepsy, apoplexy, and paiulysis 
ar» not unfrequent, and in short, nil ttio socondnry 
dfoctH of t^bronie albumijinria are obBervedtn different 
caaee of gout. Many of tbo above disorders occurriDg 
und«r duch eirciuDstaoces are oonadered as instance 
of mitphftd gout, but a strict pathology wilt Kurody 
allow of their being thus olnsaificd, although they are 
intimately a^wciatcd with the gouty diathesis 

The long cntttinuanoo of a dcprarcd condition of 
blood abo leads to fatty degcnoratioii of some of the 
tiamcN and tltiu is fit!qu«ntly obscrrcd in the heart, 
and may i>rovc Uie caaao of a fatal termination. 

r r 





''""'^; The rt.«.o« th, 
oftiemcoi,Jdrdot«t« 



LEAP P0IS0S1>"C IS aOUTY RtnUKCTS. 



tn 



hocpitBl pneticc, for it wa» found Umt from 25 to 30 
per cent, of such i^tuty puHiiite under my L>aro 
hud Locn iiffii-Gto)! oithur witli lead colic or paralyns, 
or at loa«t i-xliibitcd tho clinroctoristic kluo lead Uue 
upon tbo guDiA. 'Die influcnn; of lead in inducing 
gout was also rcnd<Ted probiible by tho n?sults of 
somo observations in which it appcumi that the 
admioifltnttion »f tlio salts of this tndal diminished 
in a notabto degree the excretion of uric a<^iil by tho 
kidneys. Within tho last year or m I have boon lod 
to iiueipect that the converse likewise holds good, or 
that pntinnta subject to or inheriting gout are more 
liable titnn others to be affected by the abeorp- 
tioii uf lead. The reasons which have led me to form 
tliis opinion are the folloving: — I have aeen and 
heard of iniUriduals who have been aiTected by load 
frum drinking water, containing it is true a notable 
amount of the metal, but stilt insufficient to produce 
poisonous PiTk'ct' nil other individuals who partook of 
the same ; I hare also observed that during tlio 
adminiHtratifm of the salts of lead gouty patients 
exhibit4^d the blue line much sooner than Diocic* gulfor- 
ing from other diseases, and that they were uln 
more prone to cxpcricnw oolio and constipatioD. 
Afl I havo this subject ittill under investigation I 
will not discus* it further at prevent, but merely call 
tht.' atteution uf the profession to tho fact as one of 
much interest and perhapc« of lymsidcrablc importanoe, 

e'hat wine and otlier liijuoni, as well u» driuk- 
et, are posofaly often contaminated with traces 
r rS 






upon at lengtbj 
uach in detailing thJ 
few words however, id 

If an indiWdual bt-l 
fits of gout, or even mol 
g«n«ral liraltli otliei-n-j 
diet and active and 
prevent an increasing 
tbo disease, and winic 
In such cases as the 
Utod with tolerable accui 
cflooted by n rigorous at 
the expected return, nnd 
tn tlic U!»o of propwly 
dtvcrilwd, the wloctioo 1 
Uaritiut uf each ease. 

Uinernl waters act in t 
menttonod Bolinee, and pi 
■sually ec«onipnnt">1 )>v 




PROPHYLACTIC TKRATMEST. 



m 



It han been axsertcd, Umt ontchicum giren before 
the expected visitationH vxerta a bcnelirasl Influence in 
varding them off, nnd Sir Henry IloUand relates tui 
instance iu which hv ifiirc it daily in moderate do««« 
in combination vith quinine, for two yean, not only 
with i'ntir<> exemj>ti(>n fnim pml, but with singular 
benefit to the )Kneral health, when previously to tliid 
treatment scarwly two months pn^^^cd over without 
■a attack. In certain casee eolchicum may ho ndvan- 
ta^ualy so pre^ribed, but I should feol more dis- 
poacd to truHt either tu simple salines, or mIidch 
oombincd with aromatio bitters if tho digCAtirr organs 
bo moeh impaired; this treatment when judiei<>u]<Iy 
exhibited M nei'er followed by injurious i^ul(i<;, and 
in many oases has proved ho eucccs^ul as to haTv 
allowed the patient oren ta indulge in wine, without 
being tormented by bia enemy. 

Abstinence from wines ond malt U<iuors is often 
mifficient to prerent the n<petilion of tliu attnek.^ of 
gout, hut in many cases, if the patient ha« been 
nocu.<t')m(>d Co taku u-ine frt'cly, it ia important to find 
n subi«titute for it; thi» may goaerally bo done by 
ordoring a limited qaanti^ of tomo Aittilkd spirit, aa 
brandy or whiskey, in order to keep up the tone of 
tlio djgeKtivo organ.1 and of the drcalating system. 

The following eow is one of many wliicli hare 
oome nndcr my eare illustrative of the influeno) of 
absiaiuing from wine upon the retom of the gouty 
paroxysms : — 

A gttnllcman, fifty .seren years of age, who ioherital 





nitbin n mouth. Aftel 
wiue (he had bccit uocu^t 
of port wiuo ludav), imd 
years, he hafl not experi«ii 
lie had not taken any incdl 

I hare seen numeronH i 
above ; but m niedicino lia 
sane time tliut the u-ine hn 
of gout may bavo been pa 
tile drugs. 

ProtjHOfu of JlhetmaMd 
stages of rhcum&toid ortlir 
be adopted, the prognosis is 
recovery m»y be bIow. Iu 
of the disease, even u-liou m 
I bttvo several timoa ecen p 
their limb* (u a vcr}' connadcc 
the [irugntmi-s is in g<^on 



PBOGSOSIS OP. 



u» 



FrogHMk ^ Qout. — ^When a patipnt, otbonrifio in 
good boBltb, u saffiaring bum a. iit of regular gout, 
bowoTCr SOTcro it muy be, the progntms, as far ae the 
attack is concomcdt may bo coimidcrcd favourublv. I 
have nvvcr kii»wii or bciiril uf an insUincc which tcr- 
miiiutt^d fatall)-. It was a po|)ulur Ix'litf. until a vorv 
rcooiit pc-riod, that the appearance of g^mt vms rath«r 
to be desired thau uot ; tbut, in fuL<t, au attack ufgout 
poascfiscd the power of curing ever}- other ailmoot and 
of freeing the systsm from any lurking malady. I 
have no beAtation in affirming Uiat Much is not tho 
oaeCi and I cannot too Htntiigly deprccatv tlio tnatmcnt 
occasionally pursued, of onduavooring to induce uu at- 
tack of gout for eucb an ideal puqiosc. At tbu proecni 
timiOt I belioTe, tboro ajo few who would renture 
upon micli an assertion, but etiU it is occasionally 
made. 

Qout bos a decided tendency to shorten life, and 
tnsonutoo eomponiea, being fully uwuru of the fact, 
are not bai-kward in Boting upon it by incrciMng tlu> 
aniouiit of ptrmium for tlio insuranoc of tho livn of 
those who have Huffcrcd from this diseaM'. It ts diffi- 
cult to discorer any reliable .itatifttiai a» to tho effect 
of guut in shortening life, and tho rulc^i at diffiTTcnt 
insurance offices as to the increase of premium diflcr 
from i^iL'h other. 

At one office, for example, I am informed that no 
pattioular rate is adopted for gouty penou^, but the 
additional rnto is regulated according to the report of 
their own pbysieiun and that of the medical officers to 




ni 



OOUT ASD RHEniATlC GOUT. 



the company. At a second office I un told that cIotmi 
}pet exsat is added to the prenuum, whatever may be 
tho ooiulitiou of the patient o-t to gout, prorjdcd he is 
not too much BfTootod to poAH the phjnicwn ; and at a 
third ofHco I am iu«urod that from two to thnw yean 
are added to the lives, acooiding to the report of the 
medical otHcer. 

When once a patient has experienced a fit of goat, 
he is liable to its reourrcnoe ; the iotcrva) may indeed 
he prolongixi, even porb3])s to many j-ears, by great 
care and uttcutioii, but etill, exct^pt uitdt^r i>i<ouliar eir^ 
eumstanccs, a return of tho discMo may be ozpcetcd. 

In looking over tho histories of the cum which 
haTo como ^-itbin my on-Q knowledge, I c«a find but 
few exceptions to this rule. An intemJ of two yeon^ 
or eren more, often occora hdtvrccD the firrt 
second attack ; this is soon, howoviT, rcdtioiHl to one 
year, tlien to a half-y«nr, and m on, ta the m: 
beoomes moru and moro grafbod into tho oonstii 
These remarks apply to such patients as tako no care 
toprerent its r«tum. If proper prccautione bo adoptrd, 
and an appropriate plan devised nod followed out, a 
very diScri'nt oouiw may be given to Die difMS(\ 
oven when it bus acquired some eonsidentblo hold 
upon tho I'j'steni. 

The following are a few exceptions to the aborc nde 
as to the prngre»s of gout which I have met with :^ 

A gentleman, who Lived to the ago of scveaty, had 
an attack of gout in tho ball of the left great toe when 
tbirty*fi\'e years of age. from the latter date tip tn 




ntOO^fOSES OP. 



tbo 



I of his death, Ite 



accurtomcd to Ilro veil, 
ana lo panaKe trwiy ot {wirt wine, but ho had hod 
no rt'tum of the aifectitin ; he died suddenly of car- 
diae diseiee or aneurism. 

Another gcoUoman, twenty years of age, n medical 
student, in th« ^nng of tltc y<»u- wa« uttuckcd nhout 
ton o'oloek in tiic morning with oiK-rudating [luin in 
the ball of the great toe. Thifi lasted five or six hours, 
and left the part m swotleu and t«>nder, that he was 
onable to resume his studies for six days. Tliirteen 
years after he had an attack in the ankle, apparently 
bronght on by over-walking and taking some stoat It 
18 now more than tweoty-one years einoe this la*t 
att«ok, and he has had no retara, hut oceasionally 
feels darting pains through the joints of the great toei. 

This gentleman's father had g4>ut for the first time 
at sixty-eight yean of sge, the j'rar in which ho died. 

Qouty pottcnts sometimes live to a good old age, 
■nd occosionatly, in the latter port of tlicir Urn, the 
fits become milder and less frequent. A few ycare 
Mtnoo I met with an example of this io a gcntlc- 
mnn, then about eighty-four, who had soffered ftom 
gent for fifty years. Ko chalk-slonea were risible, and 
liiit general hL>altb thronghont life bad been remarkably 
good ; during the ten years previous to my seeing him, 
although ho fitill vulferrd occusiunally from gout, the 
fits had bcooine much lost (rcqnent and of a milder 
ehaiador. I have met with a few other similar tn- 
atanees, but am iucUnod to think that they aro 
wmcwhat exoeptkiuil. 




sso 



QOPT AKD KIIEUMATIC GOUT. 



After rq)onte(l risits, when gout assomcs «b 
osUicnic and ctronic character, and more e^Koiallj 
when any crippliii)^ of the joiotx oceuns, or when 
deposits bccumo visible at Uio surfim!, it will geiie- 
rolly be found tlint Iho kidncj-s luTO lost macb of 
tliL-ir uric ftcid'Cxorotiiif; power, and tbo iirioo tlten 
ofUrn voDtninK a truce uf iilbumon, tlu) Itlood at tlie 
same time bein^ londc-d witlt urates ; in tlicso com 
tiie \irogi\om ia mucli ^css favounil>Io, fur Ihouglt mA 
patients may live many years under favouraUo cu^ 
cum«tanccfi, still thoy are liable to be seriously nffcc^^ 
by intercurrent disease, severe accidents, and otl^^| 
agencies, ^\'liich in healthy subjects woold be unat- 
tenJ(?d with dtugerous oonsequences. 

Tbu folloTiDg exnmplett illustrate irhat we hare 
advanced as to the prognosis of gout : — 

A gentlemati about ti%-four yL-ars of age, inheritiiig 
gout vcri,* strongly, himself suffered from the disease 
early in life, and bofon; the ago of tliirly-fivo had 
Dotieed ehalk-!>t«nes and was soon crippled, both in 
the hnnds and fiM-t, from many of tlic uaaUer joints 
becomiog unchyluacd. One autumn, wlicn at the sea- 
side, h« was exposed to cold, and in lieu of ozperien- 
cing the ordinary sj'mptoms of caturrh, rapidly sanlc, 
apparently fiom pruslration of the vitad pewcrn. TTie 
urine of thiH patioiit was verj' polo: it now and 
then exhibited a miuutv quantity of otbuutL-D, but 
scarcely a trace of urio acid. 

Another cxamjde occurred in a toll and robust nun, 
who hod suffered from gout for many years, and bad 



PROGNOSIS OP. 



BS7 



concretions about the oxtrcmitics, as well as s«v«ral 
nodulos upon the eon ; afWr a Hovorc acoitlciit, whidi 
caused fracture of the tliigh, oltliougU ho i>rogTO!Scd 
favourably for a few days, h« died suddonly, and 
without appuront causo. At the pott morttm exomi* 
nation I discovered tUo kidnovB to he reiy small and 
contmctod, and wcighiiif^ only two und a half ouia'c^ 
each ; Uie tuhuli of the pyramidal portion contained 
whit« ctrMks <if urate of wdn, nnd tliQ orf^n prc- 
Hented an appearance resembling tluit fihowii in Phito 
IV.. fig. 2. fl, b. 

In the chnptfifii on Morbid Anatomy, other euimplM 
will bo found, pronng the liability of gout)' i<iibjoeti^ to 
bo euddcnly cut off by companitiTely slight occidvota ; 
it i^ probnhlo that the fatal termination in such cawfl 
13 dependent on the stute of thu kidneyis which can 
but imperfectly porform their function under onlinur)- 
circumKtances, but arc quite uuuble to do so when on 
increased demand Is made upon tbom. 

That even Blight injuries are luxwinpuiiod witli a 
oonsiderablc wa.^ »f timue, and the scoovity for 
iBorGBsed elimination, I have proved by tho ezuninn- 
tioQ of tho urine of u patient uiwler tho effect of a 
laigo blintcred sutfece. The amount of tho ttolid 
Dxcrotioa of the urine was found alma=it double, oom- 
farvi with what it hHdbL<en for some time previously, 
nnd thi« increased elimination of solid matter n-as 
aooompaniwl with a con^^iderablo diminution in the 
weight of the body ; it is probablu that an incrcoMd 
waato of tissue talccs (iloco lilcowiso after severe in- 




Baa 



OODT ASl) BiretnUTlC OOOT. 



juries, or daring febrile disturbance from any other 
OODse, doniaading a liciillhy condition of the kidiMTV 
in order to keep tJto blood puro. 

Besides being affected by acute i^Bcase and a«d- 
dccte, putiont^ unlb impuircd kidaeys are liabl? to th« 
oocaMomd supcrrcntion of that fonn of goat whtdi 
bas bct-n named rotrooodi-nt, iiod audi 
action, wliotUer to tliu bt-iirt, ittoniacb, <a bmin, 
be attended with much dnngcr ; moreover, in clironie 
gout, the blood rem^s tmpurv- cTcn in the int«ml 
of the attacks, giring lisc in mnoy cases to oonstaat 
dyspepaa, and hence, indirectly, tendii^ to an imper- 
fect nutrition of the body, a condition of habit whidi 
may be termed gouty caehesia, and may lc«d to the 
production of organic disease in rarious importaitt 
organs. 

From vhat has now been advanced, it will be ori- 
dent tluit tlio exiimination of the urine fortlic purpiMo 
of lucertuining how fnr the function of the kidneys bat 
become implicst«d, is of much value as an aid to tlie 
progDons in many chm« of gout. Id mnking sudi 
cxaninjition I not ouly dctvraiino the proaenoe or 
absence of albumen, but usually obtain some idea of 
the manner in which the sohd portions of the urine, 
and especially tlic uric acid, aro excreted; in some 
instances even ti quantitative estimation of the urio 
acid ia desirable. 

In oancludiug my remarks upon this subject I may 
state, Uiat I cunnder oven a single fit of govt, hovrever 
alight, should be looked upon as an intimttiou that the 




PROQNOSIS OF. 5SB 

patient cannot go on with impunity in his then habits 
of life ; it is a warning that either he must change 
them or expect returns of the disease, which as time 
advances arc certain to increase both in frequency and 
duration, and arc likely to embitter and shorten 
existence. 

On the other hand I am equally persuaded that if 
proper regimenal and medicinal precautions be taken, 
the gouty patient may be saved from such an alterna- 
tive, and the disease, instead of increasing in severity, 
may be gradually mitigate, and probably interfere 
but little with the comforts of life. 



APPENDIX. 



Injiuftue ^ Cider on the prodncticti of Gout. 

At piga 3fiT It b stated that Oider uit) similar borenc^ 
net U> tame eitont iw protliiqicMing ckuiiai of gout, altfatniKli 
probftlily a miicb luger quantity of t]i«m it Rqnir«i) than of 
tlio iitron|p;ir VwAt of malt Hqaon. I luivn beat raoeitt)/ 
favuurod by Mr. Alfred HaviUnd, a gentleman pnetiaiiig at 
Briilgtiratifr, willi auiuoouiitof huoxpericnccoti tliU aubjt«t, 
and Dr, Wo«l, of PKilodolphia, hoa alio kinttly givon nw lui 
opiuloD U]KJu tile ume. Mr. Hanland ackitowlodgM tfcat 
thora ar« donbtleaa many oawa of f(uul in the oidot diatrjcta, 
altbuiigh he han ba«a trnabla, during a long «xp«riuDM, to 
Mtablliih tli« foot of a lingla owo luinog been nally duo to tha 
diinldiig of cjd«r ; li« itatm that, on looking onr th* booka 
of tlw Bridge<Tat«r Diipemaaiy, lio did not find aa oiitty of 
a aingl* gouty patiost during a i>«ciod of 30 y«an, and 
that a pvnHHutl oiperienee of font yoan at tlw «anM in- 
»titiition haa gircn tha lam* aegativo rcnilt ; and again, 
duriug 15 yearn at another diniMiiaMy, vhon tho aven^ 
iianiWr of [atieuta it about 360~>n«aily aO agrioaltiital 
Ubanivn, with thwr wivoH and child nni—thoro rora only 
tliTM OMN of pure goat, anil thew ooowrcd in beer tlriiiken. 
la hetf ha wupt, if Um gouty «ih}«eta in Ua nai^honrbood, 
u a rulor are be«r drinkon, they at l«aat lake mUturo* of 
diflmmt Bqnofa: — 




1)Mr or wftUr. 

Uo hftx 'not met wil 
cider, Dor has ho diico^ 

He dividta cidw iiil 

The UtUr tnny or 
of the Mtc}inriii« iDHttbil 

Mr. Ilavtlui-I ttiinkn) 
but h« aanerts tluil r«itl • 
«* it ia very »pt to d«nitij 

Calouliw aiiil griki'ol 
oliaoat luiknown in tlu 

Good vounil Ciller i* < 
(Carodjr n tnoo of tOfu. 

SiMtt or imfirftflly fan 
1013, but «li«ii diiur ii w 
9ft8, yrtUtr bdng nrptooD' 

The following leUer, t 
tad otlior kicobolio beven; 
Ur. Wood, vf i>)iiliut<^lj>liig 

Ut bus Ds. Gauodv 

In 00aiplUn<« nitli y< 
jwi witl>_ 



dlafamtioit ot gout, at tout in {t« *ctibo ud mon inflAmiiiii- 
tary forei ; l«it na ttcro hnvc been other agenoiei, wliiah 
havu contributol to t)i« luiio nault, 1 uo uuiireptirwl to my 
how br it U 3ittribnt«li]e to this subatitutjcu, though I think 
it hu not hctva without dToot. 

I &m quitv Mirtaiti that I havo itoon tho diniiaM) rosnlt fhita 
Um oxonuufo utio of uuilt liiiuor, luid iiuitv ui oartain that I 
luvo uevin- known it to h« outol t>y cidnr, thou^ 1 md 
CunOiir with « comidonbb pt^uUtion who have long been 
In tb« hftbitnal iim of this htntange. 

In tk« Ooitod Rtnl««, tho tlifforent fortu of anl*nt spirits 
ban baan Urjcelj oonramoil by the ]ioaror olftrnm, caprdnlly 
whisky and rum, A» a rotnlt of thii, ) hitrn ooimtantly 
■eon in ho«r]>ital praddoa much riaMtnl discriiu! of varioiu 
kind*, and not a fi»w oa«aa of daUrinin tnniuUH, liut U> th« 
beet of my roooIlBcrtion, gout to not a nnglo ioiitaiiceL 

In mnlttng Oi« .ibovn (tatcraont I harti, ai you peroeirc, 
oonfincd aiyiuilt to umple bots, without any attempt at 
cxpUnntion. 

Sinoervly your friend. 



GEO. R WOOD. 



Dr. A.B. Outoi. 



Tn/tusnfe of Lead wi (he prodiieticn 0/ OohL 

Sincci thu publleatlon of th» fint ediliou of lh!-i work. Dr. 
It. W. Falooiicr, of Bath, ha* kindly rcnnndwl mo, thnt hi* 
gnuidfitth<?r, thu LiUi Dr. WUliMn Faloouor, iu 1 TT2, and 
pnvioualy to ihot time Dn. Miugrar* luid llnxham had 
notiood that aome relation oxixted between load poiMoioc 
Mid gout. Dr. W. Falconer, in his BHsy on the Ihoh 
Waters, pnbUdied in 1773, mokea the following renuuki : — 
"Tho Rath w»tvr« ar* Ukewiao of tho ntmoat Mrvioe in tho 
Kouty compUinU that Mmotimea follow the ooUe of PoifliecB, 
irtikh have been obanrvd and dawiibtd by Dr. MaRgravo, 

«« 




APPENDIX. 



And mm hii tiiaa hj Dr. Hnxhua.* Dr. Falooi 
pdntsd ottl other iwatngw ia voriu whidi bear i 
tUs Mtfajoet : tot numplo, in (lie nnpublUiMl vriL 
Dr. CU«b H. Fmy, pubUdied in ISSft, Uis roU««in(l 
ngv, «Ut«d 1807, otcnn :— *' OoM flrani Uwd. — I 
thai, •flu tbu pill*)- from ImA, pttieot* of k 
oUiicroiM pravuHulf healthy, ue votr ntbject to 
gout in th« limba. lilt. C, unoiig otben, UnA gout J 
foot. Mix] WM MBiBwhftt nllevvd hy it. Th«M fact* j 
that loul bM tbo powoc of produciiif uaJua 
than, d»i" 

Ib Dr. BiwitM Bwlow's Vamj on tlu Iktli W«t«t«,f 
liabod Ln 1832, tluvo auM ica moDtioDed of goat folloi 
" paUx of haiiiU from imJmd of iMd." 

Dr. R. W. Foloonar ha* hinmU, in tlw BritUh 
Joitimal, Nor. 2, 18ftl, relat«d a oata of aatamtiM 
Hollovad b; gout, and ia his lott«r makaa Uw foUoS 
mnark : — " Wv hare at ttaioa a large niunbor of 
Uad poiaaaing at tbo Hi&eral Wal«r Hoapital, 
tbMit haro baoB known, aftatr thatr looomny, to i 
gont, bnt, M Ear ai I can aaeertain, they quit the I 
thoroughlr rdierod, that union they are again 
the pobon, tiuf raoain ft«o Awm anj aaaiwiln of] 



troiuni 

d 



APPESD13:. 



SW 



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C4 VOOOO O 



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O *^c* " c^ -- O 
^ tali ^» ?■ p ^= p 

^^<5ooo b 



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o ^ o 6 o o > 



s:2 



13 '- "■ 



ai^ h^ s d» 
p; O — ai 



^^ 






o — n 



ti o 

n o 



in * 

IS ^ 



* — ^ c4 e *>o 

K CV C6 o C" '^ 



■•mA^OOOO £ ooo*7oo£ 



si 



^ra 



«4400000 i* OOo£oO' 



>-■ •* «l h3 B3 10 4« 

t- p *1 ei p "p p 
^4 o 0000 ^ 






Ob •-< f uc *^ 1^ 4 

^p^eao^^ a v<oc 
ouobooo 



^^ O '?4 11 ^9 

^ fc> p , 

o o o So o ■ 



3§ 



AOO n » H 

OVOOOOO •> OOOliOO 






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1- ^ 






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tl-l 






«4a 




t«HWlind> 

T\» Ukmia§ aaflw Hbatate what «« 
•dmwbdMtothepngniaitaf goat: — 

AgwiMwwniboiitgfty-fcuiryiiof tp».n!ihiwtian 
(out vu; ttnogljr, hhwdf OTflbfvl froa tka dinM* 
auly u> Vttp, ■nd hAm Um ag* of Uuitjr-firv had 
ootiood cluiUi-ibinaH ml wm mod cripiilad, both m 
tbo Wodt Mu) fiwt, from msay of Uw rauDer juaull 
locuminK •nebyliwcd. Om ■atumn. wlun at tbe eat- 
Me, \ui trua expotod to ooU, ood ia tiira of 
ting iIh) rjrtUtuirjr Hymploou of eaianh, rapidly 
ii)ij>urMitlx froin proatration of tbe x*itiil powcis. Tlw 
uriofl tif thill potiont wm vot^ polo: it tiow and 
Uuni cttlithitcd A minuto qiuutlily of anMimim, but 
Horci'l}' u tnwo of uric ncid. 

Another vxmmplo occturod in n toll uul robust man, 
wli« tiiul lufforod from gout for many ypun, aud liud 



APPENDIX. W 

Aitalffsis of the Kaiserquelle {Source de I'Empereur), 
Aix-la- Ckappelle. 
Temfcutdu, 13C° Vim, 
In 16 fluid ooncea there are contoioed : 

Cbloride of (odium 30-Tl gn. 

Cubonftte of »da O'Sl „ 

,, otiime 0-23 „ 

„ oi magnetic 0-16 „ 

,, ofitrODtu 0-01 „ 

Sulphate of loda 212,, 

9alphant of Bodiam 0'S2 ,, 

Pluxphate of Bod* Oil,, 

Flaoride of Mldnm 0-17 „ 

Silica 0-61 „ 

Oigtuic uiIidaI matter 0'29 „ 

31-82 „ 

Cubanie add 6*00 cub. ia. 

Snlphiintl«d hrdrogGD 013 „ „ 

Nitrogea 18-G3 „ „ 

AttahjsU of the Sprudel Spring at Carhbad. . 

TiKPI&lTCR*, 107° Fah. 

In each 16 fluid ounces there are contained, beudea » 
little dissolved carbonio add : 

Solphate of *oda 19-860 gn. 

Carbonate of soda S'BBO „ 

Chloride of Bodinm T'970 „ 

Carbonate of line 2-370,, 

„ ofmagncaia I'SfiO „ 

„ oritrnatia OiM? „ 

„ of iron 0-020 „ 

,, ofmangancae O'OOfi „ 

rhoaphato of lime 0001 „ 

„ ofaJomina 0002 „ 

Fluoride of oaJciam 021,, 

Silex 0670 „ 

41-880 



m APPENDIX. 

Amlfftu of it>t Water t(f the Haupf^tUe, tM ma/ 
mlinf of tke Tfjaitt Sprinyt, 
In ouo litre it oontaiiMd : 

CuboDiU of todft O-SMfn. 

„ ofthM O-MX., 

CUmU* or*od]ain O^IM ^ 

with traces of tr«ii, mauguiMO, iiM^iiwii. ui<l silioa. 

Atialyna ^ the Jfiiifral Waf^r «/ tfur cAi*/ Sjmmg ef 
Wil<ibad, Wuiicmbirs. 
Tumumui, iH' Fut. 
In <mIi 16 flnld oanon tliare an otatoiBtd, togBttur with 
■mall amouDta of coxbooia ad<l, ndtrogoD, 4Qd oxjrgea : 

CUurida of i«diuiu 1 -fS pa. 

CkrbeaaUofMda 0-SS „ 

,. uflitM O.N.. 

„ ofnoitnBiIa 0-47 » 

Oflron 0-43 „ 

„ nuBtanMO - .... O-Ol „ 

eiilpbi>l«, ofKila ..... O'lO „ 

.. ofpotuh •■*»,. 

■ BOm •-«»„ 

MI 

Attaiyti* of tht Burton Waltn (Pltiji/airy 
An imperiai gaUou at 60° Fab. contain*: 

KlHck fr-UapM. 

Oxida of Iran and klainloa (I'S40 „ 

CkrbouUofllm* 7*771,, 

enlpbtUofUn* S10.. 

OubcdikM ef micngM 4-US „ 

Cblorid* of mapiumn Oill „ 

„ utaoliaa S^I30 „ 

„ o(|o(Hilani S-SM , 

HhtIu (m flaoriilc of uliiuiD) 

naqbtrie acid fu )>tioapbiil* of lim*} . . . 

30'STD 

CkiIkhIo uiil lS-6S<«b.l 

Silne-ta SM-W „ 



Analysfi erhiUlin^ the lufiiifiiff of ihf. Wiohadtn 
Water upon the Urinary Secnlion {Braun). 

A Hun kWit tbirtj yna% oU md in good hcoltlt, wm put 
L ft rvg\iliiU><t aiid iu«sLgr» dit-t, tokuig cquul nticl tuotlomto 
cxoKiMk ()n tliD foturth A^y Ibo uriao nu collecM and 
ei&miii^d ; — 

Tha qouUc; in the It haan vh tS m>. (b; wolchl). 

Una llMScn. 

rriould IS'IS „ 

Cbloridecif «odliun(Miniii«ii mH) ITl'BB „ 

Wben an udditloul half pound or ordiiiAry Wktsr WU 
noxt day Mld«d t« hla diet, til* nmlU wcr« : — 

Quutit/ oT urine m tU 2i boon . , SI om. (bj wflcbl). 

XSm, DfltSsn 

fricMiJ 13'fll „ 

CbloriJetittodiiam . . . ITS'Sl „ 

Xoit Any luilf a, pound of Wiesbad«n water iru «iib«Utiit«l 
for the oriiioiiTy tretor, &nd the foUowiug n^uIU: — 

QiMDtit} of nnao in tlie S4 haom . . M «m. (Vjr wrighi), 

tin* ttl-TSpi^ 

Crl«*eU U'TI „ 

OhIoriJe or Ndlntn . . 301-13 „ 

A Kocond trial of tlw Muie esperimemt gan 

Qnonlitjr of urine in tht SI liaiin . ■ C3 on, (bj «ngbl). 

ITtM IH'Ol (n. 

0ilfluU It'll „ 

CblMldtefMdlBBi . . 331-11,, 

It in ttat«d that iu other trials the aogmeutallMi of th* 
Uiin« Taried from tirelT« io twenty ouuota, and that tha 
un», aric ockl, ornd oommon Mlt voro al*o iDcnaiai in Um 
MBW proportiou. 

i^«(« 0/ iht miixrot trabn wA«h (dUi* i» targfir 6«U 




•w 



APPENDIX. 



modnwtf do***. — Tli« tubjeot of tho aboTa extwriaunt 
agaiu Holcctod, nud tho niuno diot i>i:i«oT«rod wiUi ; « po«Dd 
of oommon wutvr wiu iulil«tl h> lua diet on tlui roiuth da;, 
ftutl tJi« quiuititf and oompcwitiaD of Um arina wm a* 
foUow* ; — 

(}uaoUty Dt ntino io tbe 24 bunn , 01 turn, ibj ' 

Una lae-vien. 

Cm Mid 14-IM ., 

CUotUo of lodlum . . . Sai-71 „ 



The Doxt d&y, a. pound of tho niiunl wUn- wu Uk«D b 
the oouinc of from half to tJirae-qnarten of an hour, mmI th* 



Qnuititj ot Drill* in tb« 14 Lonn . 
Urw. 
Drie add 

Chloride of ndlDm 



. T9 ou. (l)j 

. M«-U4g»- 

. M-712 „ 

. U9)l „ 



In three other trioli, the urino varied in iiaaDttty 
Mvonty to oighty-IIvo ouuoo«, tho utiia from 247 to SU 
grains, thu uric noid fruot ninatoou to twcaty-oight gftiam, 
and the chloride of audimu from 363 to 320 gniaiL Oalj 
oco oxpwinicnt is givon by Dr. Bntun of tlio effMt on th» 
imiio produced by thu iiftton, when taken in vetjr laigt 
doHB; wbeo 

Qntotltr of arioe In Iho 34 bann . 48 on. (t? ' 

Una 114-13 (IS. 

llriewid lS-91 ., 

Cblorido of wdinn . . . SS4'U ,, 



In itnothor obMrvation the qiuntitiea only of Ihe aria* 
.Iran detcmimod, and foand to be fifty-throe awl fifty-one 
oimoN nspeetively. 




4 



The pbyikJogioal «ff(«t4 produced by tho uae of 
WBtora, in tho form of cithor the topd or warm liath, Kpfttr 
to be th« same a« thoao induood hf a mixture of aam- 



APPENDIX. 



001 



moB tad MS valor, and I botiovo tluit no imI dlflTereuw 
oonld bo dkUnguialiod botn-twu tlie ufloct of uno toi Um 
other. 

^fiett of ttpul l>(iM« on (Ac uHtm.— Dr. Bmuu lus njao 
^ven in liJa work tho cffoct or theM bathn uu tliu uriae, 
ohoonug for Uio ubMivutioiui a. mou, prcrioiuly |itii[>mix1 b]f 
k n)giilut«<l itiot, kud modfrnte •xtrdM, On Um thnie dafs 
of thi* <l)at, tho oxuiiiiuitiuiii of tho urine gkvo tho foUowiiig 
Rsulte : — 



QtuuiUtr of Brlno pHwd In tin 21 luon 
I'n* . . . , 
Dricatad 
Cblorid* of lodiDm 



IS u S4 oa. (br wel(b& 
no to ISSgK 

Ills tS „ 
leOialTfl „ 



Th4 D«xt dftjr, iih«n tftking « bfttb of onlinnxT wnter of 
half BD houf'* <lurolii>ii, at the temperature of about W 
Ffth., the nttmlwra wero,— 

■JBuUtf of urloa in tbo tM biinn . 39 on. (bjr *tJ(ht^ 

Tim Itl-nsra. 

UrioMia .... 11-81,, 

C9ilorUaotKHtiuai . . I74'll ,■ 

On the fulluwiug lUy, n liath of tho minonl mtcr wu 
talna kt tibout tho lAmn tomponitnie uhI o( tho iktiio Oum- 
tion, ud the eOocta of the urine an eeeii to be,— 

K OM. (b7 Ml|fal). 
. 1814a pi. 



Quanlity of arino la Um 31 koim 
Una . . . 



Ohlori Je of ladium 



13-01 „ 
10O-(« „ 



I 



BepetitlouB of the expefiment gaTO,— 

QDMltt)' o( Ulino in the SI bonn 68 c«. (by wtlthi). 
l!l-31tn. 



CrM 

Crlo acid 
Chlorido of Mdiam 



16-03 „ 
234-13 ., 



^ThvQ tho oxpeTimentA ir«ra Boltiptied, MBieirhkt vaiuUe 
remlte were obtaiuod, but then wa* alvafi produoed by the 




«os 



APPENDIX. 



uo of tbo minvnil m »iif;tnnDtntioii of tbo qiMBtity of tirina 
lo tlw extent at si)m« ouooea, «nil at Um hum tine a noiaUe 
dUr«reiio« ia tbo luuount of tht cUorida of mkUoxiI. 

^tcU o/hot baHu on the tirine.^WhVi tho teinpent 
of the bath waa tnoi«aied to 07^ Fall., the nmlU 
modified, And wore as foQan : — 

A •abjoct pUocd in oircuDutauOTa rimilAr to thoM 
Isdioattid, paaiiwl during ttuiM dnyii from forty-two to Cor 
in oimcM of urino. On tlie fanrth day tool: a bath 
ovduiiu7 yniUrr at tlM tempemtiira of Qf Fah. : miMib 
apiiatioii took plaoo during ajul afW tbo both, aud tb*l 
urinary twcrotioD w** 

Qnuitil; in llir 31 Imura . ■ . SQ*S au. (bj wd{hl), 

UrcK 16T-n e™. 

CrloMld . . . . ]a3S„ 

ChlurUaofioJlaiii . . . 191-31 ,, 



Tho Muae r^mea bung Mntiniied, on the thAii day ■ 
bath ot mlnend wat«r ftt tho temiwmtur* of 97' Fab. ma 
taken, which produood mncfa pnnpintioD. 



DriM in tlie St honn . 

Clio add 

Cblgtid* of •oliuo) 



97 on. (If vn^l}- 
IWI „ 



Fitrthor «xp«ruii«uls exhlbitod a diniiautioD of Iron 
to ten oiiiun in tlie (]Uanl4ty of urine ohm a miaon] hot 
bath WHB U3Lil, auil from one to Bto onnosa aflar tbe oae of 
tho orflinnix bnt bath. 

From «x|)crlmeut8 made on the ponqMntMB of paticnta 
aubmittod to tho themal Ifcfttucut at Wleabadcu, it mnld 
appeal that neither tho intenuJ nor oxtoreal a*e of the 
wateiv haro aajr efftct fu incrcoaing the amount of 
aalt contoiMd in thepet^intloi^aiidtlMnfanlhk] 
dooa not appear to be olimiuatcd \yy tho akis. 



APPENDIX. 



80S 



Analyset exhibiting the Injiuence of Wiesbaden Waten 
upon the Urinary Secretion {Neubauer).* 

The results of iCTcubsiier, refered to at page 476, 
differing completely from those givea above, will be 
seen in the following Table, in which the amounts of 
uric acid contained in tho 24 hours' urine are indicated. 





Minimum. 


Uedlum. 


Mftxlmmo. 


FiBST IlDITIDDAb. 








a lAltng u nnul (S iaji). 


0-si en. 


*-S2 gn. 


9«lgn. 


P Taking & batt of v&rm 1 
vatcreuhdayforluUfu)- > 
tioiu,>t82°Pkh.(SdftjB)) 


BC8 „ 


8-79 „ 


8-18 „ 


7B>thM before, inftddition] 
towbich abont 17 or 13 t 
fl. ou. of Wie>t«ilen we- 1 
ter (EDckbnuiiieu)(7dijB} ] 


a-01 „ 


*17 „ 


772 „ 


SioDiD Ikditiddil. 








1. Living u oin&l (8 dajn) 


E-OB „ 


7M „ 


10-3* ,. 


2. LiTiDg u $, fint iodi- 1 
Tidiul(5d&ji). . .) 


710 „ 


B-28 „ 


12-60 „ 


3. Lifing u 7, fint indi- ) 
Tidoel (8 de]>() . . . | 


4'fiS „ 


7-87 „ 


lO-St „ 



* Extracted from Thadicam'i Waik on Urine. 



flU 



APPENDIX. 



Pre 
M&LB3. 



Xstu. 



Q.I. 



;.j. 



w. K. 



T. W. 



aw. 



J. a 



J. 0. 



I 



30 



31 



30 



3J 



M 



67 



ZS 



J. A. 



at 



Oeeucwiion. 



HulilUarUfs. 



CtbUMI. 



Iis«n-ilt«- 
per't'iiiui. 



Cupenter. 



IVUor. 



OccUtlDCII- 

g«r. 



CorpwUr. 



LabflurtT, 
Utolf a pat- 

m&n in > 
pnbL«-bunM 



Cabtun. 



HMtditur 

prwHapoiKliiii 



BcgnlBT, 



Ktsiitur, 



BcgoUr. 
Tuupontc. 



TTiunllf not 
Urn wcU, 



NatglTm. 



LiTM woll ; 

DDt iotcm- 

ptrolc; 

kDlittl«E>D. 



IftitaUU>L 



(hMcdMBk 
otbmUk. 



Kone U> 

rliinmktina 

(ff (onL 



Nan« to 

(oot or 

rbcuiuliEiD, 

liilhcr sub- 
ject to rbFB- 
mntiim ; 
■iiuri euilI 
hrollicn onl 

N«SC «UMil. 



faUitiT en 
blber'ii (Ills 
ulTtcM «ritb 
rhtiimalim. 
Koa« ta 
vralor 
riwBMtiiDi, 



HatfU(«(L 



lfa,«faUMK& 



0«odtIU ThMM- 
UhMl lack, nm 
rbooOAtiiB •bt>Utf|bt 



I 



TnOjgxii. 



OutMl, 



Qood. 



Qoa<l. 



. 



0<M>L 



SwoodU- 

Udk. PIM 

Ihrco fiui 

bctwi. 
PlntaMA. 



Pimutaek. 



PliAl 



.PlntatlMk 



Sol lOoiCBtjnntUlMk. 



Qooi un hal 8*eiiod M- 
Ud Wk. PfaM 

iliiiiniiTiiM lutock ri(kl 
■iaot ; 

■fctttd. 



Wk. 

■ LuMk 




>IZ. 



• 



tiU ^Md ictu ptrformtA jar (ha jwrptM <^ MMrtaxwxg Iht 
Urie AM. 

UAtBS. 



Ouitt irf. 



I Cold. 

StMM- 

■toll 



Kane, «i- 
OQit mutt 
mogbl. 



Gold. 



ObU. 



ftfnat't^tn* durttie ttUtok. 



OoamaoMd in kiiM<, »n«Tw>rd* 
tbonlilar, cUhi*. Skin pcnjnral 
fimUj. PiiIm 12. T.iniuu wbiU^ 
hirnli uiiral mvJvnt«i n» upprtitCL 
Bli(bt iwrituilitii ; sM hwtt 
kffwtion. 
OsaiBMMCd ia fnt, Utcn in knns, 

lutd. ToatiMnimd:na>ppetltc; 
Ibirak No tudlie kttKllon. 
OuBDimcail in knMm ; Ihm 

WtkU, ultlM, MWl fMt. PoIm 

8^ Iwrd. ToiCM fiUT*l ; akin 

bol. No nHiao K0<ii:Uoa. 

CSonuacDM-liu right ahoalilailtiMi 
left laflcnrardi right kofc Jmnu 
DDlttrTMDtelydbeltd. PoImSS, 
hud. Tsiifiu DQl fumd ; *ppctlt« 
modtrmtn. Ka hurt »flccliDD, 

Ccmmfnoed in lu|<, Ihsu Ivfl 
&nkIo. knee* ; klWnnls vritU 
UidhuiiU. PalKSft, liai'l. TonKUS 
farred ; thint ; no npixtjta^ No 
piltliig on pnwBN. rn« ixiipir' 
ktloo. No hattl ftSoctloo. 

OamBi«no*d In lift kne* toil 
tbl^ Umb right Am ud in«te|> ; 
•ftwMib ri|bi «Ib*w, FtlliDE 
on outer lido of fvol Tinpic fartp). 
P'^Im TS. Hn bwit ftSiirtioii. 

■.Vimnicsoed in rieht IbUb. thou 
kwet bML thoaUm IcA ellw*, 
vriMt uidWd. No pitting of dw- 
nm al hud. Putn 108, nthcr 
bnrd. Tbdhu* fnmd ; pcnpliMloa; 
liunL Ms fatut tffoclIoB. 



ComtneDotd in Ti|ht hand, tbni 
fc«<. kntM. ahmtdan^ nnd hip*, 
■Ad uikl», uid left h>tid -, «1m 
llna«n. FuIm in3, harJ. Tunra* 
famd ; lliint ; iu> tppctitc. K« 



Stiita of blood. 



dot firm. ■liflhUj 
biiBtd ; Hnini »Ik>iiD* ; 
■p.gr.lOVTUIatUU'P. 
Ho InrM of ariR uiil. 



QotGrni: alltil« cup- 
ped; •eruis klkalino i 

no trac« of nri« a«id. 

Clot DDrnwl; *(raai 
aUaliDO; op. (r. 1038'04 
•till* P. NonniiNid.' 



Clot bnffcd ; not mp- 
pcd ; Knim ftlkallnt ; 
■p. p. 1028'4 at M" F. 
K« uitgicfaL 



Cinl tna ; amim 
alkaline ; ■!>, gr. 10J.»*8 
il4S'P. Koorioaad. 



Clot Donul ; ttnim 
alkalin* ; ip. gr. 1019'3 
mSKF, NoBiictcid. 
Itliirrr jtutJ, Ho ntia 
add. ] 

t-Iot lUckUj InMtt 
nnd copped 1 «nudlu- 
lino; ip. B. lOSOtnl 
<7* W. Ko iiiio send. , 
SNend ; CIM **i7 diihl ] 
boM ; nna alkklina: I 

Ha uric Kid. j 

dot liul* boOodlj 
firm ; Hrum nlhalinaij 
■p sr. l(rS8'0US3*R^ 
No inMof aria add. 





«a« 


APPEnnx. [^^1 


Sant- 
CO. 


1 


. OocupaUoD. 


bMtiDfllb. 


8«(dII>aT DnwkUuia ^H 


SO 


Cupciittf. 


RtgnW. 


Kone Id Quod. RiMMI^. 










gout or 


K 








tbwmillwn, i| 


^V 1 ' 


FEMALES. B 


1 H. H. ;9T 


SoTTUtt. 


RegaUr. 


Father LmI 


"— •'-]-T~."°fnn«Hii^ B 


1 








iheoaalliDi 


j^aco baU 


H 


L 








^DOl MUM). 


BmiptaSl 

rigbtrib 

orbM. 


i 


1 


32 


Drannuker 


BogoUr. 


None to 

goul or 


PnMrgaod 

imlUhMj. 


a«Md>i- ■ 

Mk. rinl ■ 
■MmIe «a» ■ 

MWBtd ■ 

•bMlfaor ■ 
■tMkiaff. ■ 

SHMdM- * 

tMfchad 

bMMMf 

iMadlir 


1 










■MiiTwtAa, 


L 


<0 


Ukrrlod. 


KegnUr. 


rkaumMlun 

of (soL 


Qdod. Ssawdafr- 

MtMk It 

T<an«lBM, 

all jomto 


B.K. 


» 


ScrruL 


RegulAx. 


Hat Maud. 


•OMid. ■ 
Soo^ StCDndal- ^ 


/ 












aitixk uta* 


&a 


IT 


SoTTUt. 


&«CaUr. 


RoD« to 

goat or 

iLniuLitm. 


Ootd. 


FtmattadL 1 


8.& 


2« 


Uuritd. 


Bcsubu. 


Uotb* 


a«*«M<n 


^1 
Fimuuck. 










•i«hiir 


udr. 










i^funati« ; 












tnw vTOuitt' 


^1 










IiMl»d3 


^^^^1 










Bttai.'ka of 


^^^^1 


^ 


I 


^^ 


^^ 


rbcunuliBn. 


-1 



APFKKDIX. 



at. 



Bjmplii&iA durtiiiT itttkck- 




CM. 



CM. 



0»ld— T«k 



Km gltea. 



Cannstaocil la iUfferelit Joints at 

lower. tbcD upper (xtitimltiMi; bcAb 

vrtiu mueli oruUn. Ko b«ut*f- 

tKtlon. PuImIOO, huiL TWm 

I famdi ptmpEi*!! iimi^h ; Uitnu 

fKMALS9. 

CommWiMil «>lh Inoiiliitia ; tfler 

•aDiB dtji ri|[ht foot >uil aakln, 

Iben kocii^ tbm wriitouid (bonl- 

d«T*. Blight parinnUUi. Ko 

fitting on jirMnin. PuIm 130. 
oDgoo foned ; tltint ; iig tpiittito : 
ptnplfM frail;. 

Pint -. wnnmoml ab«nt taut 
■nontbB niua, ■■ ui tilUek of aeal* 
thfniaatum. with seailr aU joialt 
kSMtfd. uid ■oaa h^jt tflbclioa. 
iNoIialMapiUl.) Seoonil: ill joint* 
■KoMod M btfbi* ; after sifbt »«lu 
eune bio b«plt^ vlUi (Wtlliiig of 
wrltte nod dorum at Iiaodii,u>it unw 
■lull joint* of Snctn, knew uodor, 
and Inrttlbaw, ihonliler aomewhat 
jiunfuL f ala« S( ; not TtT^ febrilo. 

Conmaaoed in nbonldcn, Ihim 
anile* : aftorwaid* tibowit wriab^ 
kncM. Ko beart aActica. FoIm 
IDS, bard. ToncwhrmL 



BUIaotblMd. 



r 



OammatiMd In left bot and aaUa^ 
then right hand, wHil, and ftngsn; 
aft«nranla kMM. Pula* 100, haul. 
lbD|oa rumd ; pcnqpaniliop ; tUnt. 
Ho markail Imrt aAolion. 
CUd. ObBnMMcdlnknea^tbenatnocl 

aUiUiitaorboAf i laAwriitt rifbt 
kne* and ankle fapKlallj w. Polie 
150, hard. Toagiu forrod ; naeh 
penplntlan. Kuducarditit ; p«ri- 
auititi*. 

Hoi known : Commmeod in knoM^ then BBklca 

]«rba|i« mid \i\A fnt: afUrmnU huuh, olbomh 

frmti >nrl ihnuldMa. Ko houX aflbctioB. 

«a>i< ' I "0 pnssn of dmam of 

< ' I'lila* \0\ Laid. Tooia* 
lurrr-i -. modaraie p>n|iiraUaa j 
thirttt ^. 




Clot bnffod, fopp«d I 
tarum alkaline ; fp. a. 
1028-0 at 71' F. No 
inMofnrteasid. 



Olot Rrai, ilightlr 
bnfltil ; mnoh eoppcd ; 
M nun alkaline ; in. gr. 
IOSe-7 at 03* F. Ho 
tnoeoriirioMlj. 



Got not bnlTed or cop- 
ped ; toruui alkaline ; 
■p-gr. lO^t'OalSlT'P. 
Ko tr»M ut Drie add. 
Srrwn o/ tliHtr dear, 
pall ;<llowi ip, ft. 
lOSB-0 at M* r. no 
ntioKdd. 



Slood tomin by tkntd 
fxparinwat. M* tnn 
of sricHM. 



Clot Am. eMUr 
bnllffl, aud cun^; •** 
nun alkaline ; tp. a, 
102S-S at CO* 1^ Ho 
arieaeid. 

dot bufftil. eligbCr 
capped ; rennn alka- 
line, ip. gr. 1021 08 at 
<0* F. Hi otic acid. 



Clol Am, iH^itlf 
enppad and b*fftd ; m- 
ran atkalln* ; ip. cr. 
loiT-s ai a,- P. K» 
Incaof uno add. 





1 


m 


HH 


iHH 


■ 608 




APPENDIX. 


1 


^H rmm. 


s 


OanrMut. 


HthluelllJft. 


ntndStanr 


" MbiShS'*"'-*-*' i 




■n BBWIr 




H 


ss 


UkiTlnl ; 


Sesnlw. 


Bod* la 


KolTWJ 


Rnt 






» UanilnM. 




X»ql«r 


SMd. 


•UMk. 


^^^ M. A, 


26 


Luukdnw. 


B«riltT. 


Rod* la 


Good. 


FM ^1 


^^_ 








rhmiDklJiiD 

or goU; 
or quM^an- 

■blala 
rhnmstiiiti 
from btho-. 




•M>*.^H 


^^^ 


St 


OMk: 
widow. 


lUgnltr. 


RanaU 
or gont. 


Oo»d. 


niMMUA. 

tUnjjMfi 
bobn. bM 
doaUM. 

riatote- 
miaioa 
budi. 


H H. A. 


17 


StTTont. 


B«g«Iw. 


Roiir to 


Sol »tr7 


Pint 


■ 








rhcumihUtm 
ui gout. 


KOoil, 
W«a aod 
hjnUricaL 


atlMk. 


■^ *.C. 


JO 


8«mnL 


B«(nlar. 


ir«M to 

or eoM. 


flood. 


PliM ^1 
4tUck. ^^ 


■ 


SI 


Utnicd. 


R<cakr. 


To rbniinft- 


FnlirfiNd. 


n(t4 ] 






Hoiudialil 




tiraon 


Soljen at 


•tiMk. ^^ 






work. 




bUHraod 
nsthn'a 


one time U> 
hlotlng 

DijMeHa n 




^L 


■ 


UttrM. 


BigclH. 


TorboDinv 
(Inn Oon 

niMbir. 
TwamCcn 

•flMIMd. 


Per bM taw 
7mt« bM 
born ia a 

wwkiUIr 
oTbaUlk 


Phot ^H 

BllKk. ^H 



^^H 


^^^^^^^^^^^^^^^^^^^M 


1 


1 


W APPENDIX. «0» 


CWMOOC 


8]nDptMni dnrlnc itUtk. 


EMaoTUaad. 


OMiDd 


OanmeiiRd In aeUm^ blpi^ and 


Clot firm, eapfd, 
liuflod; Mmm alkiUna 1 


du^u 


knoei, tlWD tu jcdntBof apptr nrtrc- 
mltiu, Nn bwrt ■Aetioo. PaUu 


^^^^^1 




■r.lr, lU»lUaieil'P. 


^^^^^1 




I14,lui4. ToDgngfiiind ; thitit; 


No tzaaa «l ntia aciiL 


^^^^H 




00 appttiU. 




^^^^^1 


Dold. 


UNUMDced U ikonUcra, then 


CTot iinu, baOisit n- 


^^^^H 




Mum, tcBl, and LJp>. Slacv udmla- 


lUi cnppcdi acciniial- 


^^1 




•Ian, tMUw, kaett, albawx wrUti^ 


kalln*: ^a. 10M-« 
at DO* P, Ko tnc* «f 


^^1 




acutdr InlbiMil. Pol**, 130, uoi 
full. FsiniR«i«BMJaliili[liti mQeh 


^^1 




nrio add tcr tbiwd n- 


^^^H 




ntnd ptniiinUon ', brnjiut (Uirol ; 


pfrimanl. 


^^^^H 




o xpptliUi PcricaidiUB villi affa- 




^^^1 


^ 


CominRiDtd In hip, tbta Id ImKa, 


Clot finn, boSi^ n> 
th«r oappail ; hdibb aN 


^^^1 




Un vri)!, kfiJ (lonam of baail. 


^^^^^1 




Utll* pcnpiraliAD. Fitting of haml 


kalioa; tp. or. 1024-8 
at «0* F. H« tr»M af 


^^^^^1 




■nil Itv "" pTCMon. Albimunuria 


^^^^^1 




wbta idmitkd. Ttri- and tnilo- 


ntk adid. 


^^^^^1 




eardiU*. Qucfj il nr; rcotnt. 


• 


^M 


_ CUd. 


OommeiiMd hi botk ankica, then 


dot drni, nomal; 


^M 


1 


bctb knaM, liipw liiauldtr^ dboiri. 


Mtani alkaUna; >p.Er. 

loso-asaie&'P. No 


^^^^^M 


■ 


wriib^ and band*. No idttlnf an 


^^^^^M 


■ 


linMim, ViUmr, 130, liud. TosgaB 


Ino* of DTJe add. 


^^^^^M 


P 


fentd. «lula 1 nmob Uum ; no 




^^^^^M 




KppctlU. OiitlDf t cndocardJIii. 




^^^^^M 


CUilmUe 


Commtnccd U kucti; bcartcatlj 


Clot finn. aancvbat 


^^^^^M 


fal. 


bOkKiI ; Iknn liii^t ud •honldon. 


bulM ; tanim allkUoe ; 


^^^^^M 


B 


T»afiian«chfl>n«di UMhUuiH: 


•p.lT.ia2fl'flGal«0'F. 


^^^^^1 


■ 


DD appttita. Polw 110 vbcn 


Ha bw* of ark acad. 


^^^^^1 


■ 


admittnd. Aortic ittpinE'UDt 




^^^^^1 


P 


mittnsT. PtnpIiMioa modcnM, 




^^^^^1 




Endo aad pai-canliUa toij Hmro^ 




^^^^^1 


ItMtM- 


AIIteU«siif linear laiklta, wrUU, 


Clot flm. Uitflitlj 


^^^^^1 


r 


■bouldatiL UodoM* pnaptTatJas. 


buSad and capped : •»• 


^^^^^1 


folaa 90, uedenlalj full. Timpa 


mn alkklina : ^ tr> 
1038-S at CD* P. K« 


^^^^^1 


liiwn, (iuTtd ; thinl ; no •pprtitc. 


^^^^^1 




Slicbt todoeaidiii*. 


tnta of uto aeut 


^^^^^1 


caiapa 


ComnMDCtil lakuMv ^^ MiUea, 


CloiarB,ba*d.np- 


^^^^^1 


■lamp. 


bi|«v iboDldan^ tdbMn, and domuB 


pad; amm aftaUaa : 


^^^^^1 




ofbudL KofMet- PatM les. 


nr*' IMC-* at OO* P. 
HauaM«fD(feaciiL 


~^^^ 




T«acBa Ainad ; IhM ; aa *9ft- 
llto; pnapintka ■odtntci Ha 


^^^^H 


^B 




^^^^^1 


I 


b«wtaflK«WD, 


4 


^^^1 


k 


1 


J 



81 fl 






AFPEXDIX. 






N.IDUL 




OceopaUon. 


Habit* ofliTe. 


imnlUiiulUau 




E. W. 


43 


Mu^ed. 
TalEP9 in 
najiUng. 


B«giiUr. 


Ts TLiumn- 
tlnn rrom 

■iiler 


a«u(L 


(*9k. ^* 
UUIM 


K. B. 


J3 


Wiiloir. 


BegDUr. 


Togetrt 
horn fiitlier. 
Two lini- 
Ibenlud 
isont, and 
une aontc 
rlieaioatitln. 


Terr 
ottMf. 


Rirtatl^ 


E.I'. 


la 


liomo. 


SognlM. 


Tu xhenma- 
lima from 


Kot MlODg. 


First aluM 










miither. 




J, S. 


:]3 


AIuTi«d. 


Not stated. 


Ha iendcni^v 


Qmd. 


PirAiktUci. 








LivL'3 poorly, to ^nut. 










' 


inautBcient , Pnllier hiu 
fui>J. rheumatism. 






A. B. 


2J 


Sonant. 


Regalny, 


None etilfd. 


Good,«fept 

rLsumatisiu, 


^!«conJ It- 
lack, Finl 
attiiek Dine 

:k]l joLttta 


K, IT, 


31 


Iitflrrieii. 


lic^ular. 


Kol slated. 


Good until 
Litel^; Hincc- 
l.iil einfini'- 
nitnthrisfcU 

viry weak. 


Flnl Bttirl. 


M. A. 


33 


Scmnt. 


Livod prett; 


KdEC to 


Gljod. 


KLril attack. 


S. 






well; 
worked hntJ 
in EPnenil. 


guul or 
rlieuuinti^m. 






M. B. 


IC 


Strmi.l, 


Kutfulai'. 


None la 

gout i>r 

rlieuumtiBm . 


GoiKi, 


Firatstlsck. 



I 



APl'EN'OIX. 



«ll 



Cmamot. 



llymVlaita itnitng attaok. 



SIMvothload. 



NoHM- 

figmi. 
K KeD« dii- 



Cold. 



Dmprai- 

luafi«!«iit 

N lining 
ill lid wLcD 
ftdmitlcd. 



ftnnUgkt 
OtLlaia. 

tridnit 

BOM 

L knovui 



Nnt known, 

UtrI iu 

Lsttdon * 

■uonlh. 




OoDiiaNiBed in fool, then know, 
tiiin, one urtUt, Blionlder, aneclM 
ot can lido of seek nod bud. 
PnlM 90, luvrJ. TuDgiic wliil*, 
l\iiT«d. rltllnc o( wrifil uul b&nd 
w jirMmr*. BnilucvditU (il'glitl, 
olil probabl7. 

C(inua«nK<l in 1>II bip, thin in 
uklc uid knae ; iftcmnla wriM* 
Mid d«niiia of liiuida. FiUia^ an 

preunie. PalM]OS,flaUnidhud. 
Toaiaa tarrei ; (hint ; no apfcUto. 
Ko o«ut kOMloD. 

CbnungMed in uikLn^ alUriranli 
in koM^ (Iiouldoix tlbjin ud 
miiU. Mill joluU bX buuli. Paljc 
1S8, lunt. Tutiiiua fund ; p*r- 
•pimion mnUralc; okin bat. Ko 
beut lAation. 

Aw nBimiflfi l in i^lniir iiitJmc oT 
liuli^ p«ftt tM nock lAooUd ; 
«1m donom of foot ; tbaa bii^ 
right inn, viiil^ hud, tx. No 
bMrt affcotian. Fnbo 100, Iwrd. 
ToDguo fum<l ; lUnt. 

Commmuil with erjUKusa ociia- 
•oui, tbon jabt kAoUdU; bolb 
bnulf, (Ibm^ ksMO, ud fott 
Hd bMUi ftflaMioD. fnlM 11P8. 
TonKiu fnrml ; Ihinl, Jcc 



OsBiBttotd la jobU (4 iDim 
•xtranitiM ; then ibonldm^ «l- 
brin, wriMa. Mo MrdJM kffcMliiii. 
F«1m BS. loDgoe futrod i Utlru. 

CbmncaMd ia licbt wriit, thm 
rifbt ibootdn'. SUthteDdoairditui 
Pttlw 110 ; Ihint; per«i«niti(ni. 

CBmimneed la lift wriit, Uua 
rigbti Uun ri(hi tani. PoIm 1)5, 
rotbcr htnL Tootn* ftintd ; nn 
lurkedpfnidnttea. Soniipiulnj 
o*w donon of Ax4. HecBnliu 
■ffMtkfi. 



Clcit hnSml, eoppol j 
Kram alkiliii* i ap. gr. 
10S9-0 at iff- F. No 
timee at uit acid. 



Clot Gnn.l&rgc^bnSed, 
•tiillitlf cupfitd; aeruin 
aJknllne; ap. rt, Wili t 

at 33' P. No Uiuo of 
nrieuid. 



Clot traffttl, (uprH ; 
Mntn olkiline ; ap. it. 
lOlSO al 63* F. Ho 
ttaeo of vri« aud. 



Clol Em ; aeran ■!■ 
kalino; ap. gr. lOIS'S 
al 6r P. Ho UaM of 
nrioaeid. 



Clot aUghUj bAd; 
■■nun alkalisa ; ap. 0. 
1O30-8 at Sr P. Ho 
tiaM «f arie add. 



cut bnBcd, Bwh cnp- 
pei; wtniD alfcalinai 
■n.Br.l030-OMM*P. 
novTisKU. 

ClotWOHwirtiaiAod 
and eoppod ; mnnt al- 
kaUna : ap, (r. 10301 
at a* P. So nrio add, 

Clol tinStd, moda- 
nUtj cujiptd : wroui 
alkalinaiapfT. 101!S-( 
al as* P. tto tnee of 
■twacid. 



^.-^^HIHI 






APPEKDU. 




■ IhiM 


Bml 


AMsunl et pitlnt. StiM cT Utad. 
1 




1 N.K. 


IL 


gWMd b7 K phjnohn. 


tJM: ifk n. lOU-o *t 


















wpwimiM gtn am Iom 










of arid MM. 




■ M.a 


». 


FkliMl nSirtiis ftWD mil' 


Btlmtr MnM alkalin: 
■p. (r- 1M4-4 Ki «r r. 






^ 


qvukr mdm in wrirt uil 


uid Ibrad ■nail— 1 








Qmt IM ntrw McoUl, 


|l 






Ko cnrt in funUr. 


^ 


A.K. 


M. 


A«ata ibwimMi— . di>- 


CM 1(4 boOrd, Md 






p<iMd b| kpLfnelak. 


MBtirbM oarf«d; ■■■■ 
■^^■"m; ■«■ p. isn't 














txpttimitat ^T« •• bMt «f 








srlowid. 


A. D. 


^ 


FWi»t *ilb Mot* rWO' 


MiM-,<md.-wn«aI- 






Biitlaa and pccio&tdltU. 


«0* P. Ko tiM* «( ari* 
■old b; AiMd ei]>«tl««L 


Q. 0. 


11. 


Sub-ieitU rbanMaUOB of 


fftiiiti- tmiiB ; Mn« 






i«<<tnl jttn' (tudiiic. 


alluliiic ; an. fr. I0SS4 
■iOO'P. li*ari«MMl9 






Uraat tM DOtsr aSMel ; 






wcalkar *ad not diit ]v«- 


urit-acU Ibmad nrwitttav 


I 




itaeNanHrtatliu. 


1 



INDEX. 



nag 

19 
U9 

281 
11 
10 

217 



Abscimu, gont; . 

— trmtmeut of 
Accidanta, a caoH of gout . 
Agineta, Timra of , , . 
Aetiua, viewa of gout . . 
Age, inflasnce on gout , . 
Au<la-Cliapell«, aaaljitt of 

ita mten . . G97 

Taino of ita 

watan in gool . , 478 

AlboneiiiD the orineinacate 

gont . .1.12 

— — in chronie gont 183 
Aloobolio liqnon, inflnenco 

oagout. . . 2G1, S91 
Ale, prediapoaiog to gout . 25C 
AJkalie^ in the treatuieDt 

oFgoul . . . . 107 
AaunoDia, phoaphute o^ in 

goat .... 410 
Analjnia of blood in goat . S4 

urine in gont , 144 

Anchjloaii fiom acate gont . 47 

— — chrooio gont 61 
Animal food in gont , . 2S2 
Anodjnea and DBrcotics . 35S 
Anxiety a Mnae of gont . , 265 
Arabian pbfiicions, th^ 

Tiewa on gont 12 

Areteni, views of . . . 7 
Aah-leaTU in gont . . 42S 
Anretianua, Tiewa of . , 9 
Anthor'i TJews of the onra- 

bilitjofgont , . 344, G33 

— utnnofgont , 316 



B. 

ILUL or greftt lo«, freqoenc; 

of DccnircBce of gonl in. 2 1 



Sail of great tDa,UbUahowiDg 
condition of in 20 not 
goat; «nbjeet4 . . 335 
BathvaterB . . . 4S4 

Blisters in goat . . ■ 361 

Blister flnid in goat . . 123 
Blood-letting . . . 3S6 
Blood, condition of in gont . 90 

— diicoTerj of urio acid 

in . . 95 

— — nrea in , 126 

— of oxalio aeid in . 127 

— in lead-poiaoniDg . . 275 

— eiocee of nrio acid in 96 

— in lusDte rheumatiim, 604 
Bonei, ansl}^ of in chronio 

gont . . . , 183 
nnin, gontj affeetian of . CIS 
Brodie, SrBeDJamiD, dimec- 

tion'of a goutj aubject . 175 
Boras JIacoam affected in 

goat . , . . 70 
Boitonwateningoat . 4S3 

— — analjsii of . 598 



C. 

ClsLaBlD waters . . . 433 
— — aiialjsis of, 697 

CaitUage, alteration of . . 21!) 
CaMi illnrtralirs o[ acute 

goat, 29, 30, 32, 
aa, 34,35,36, 39, 
42, 43 
— — of chronio gont, 

OS, 04, 66, 69, 70, 
71, n, 82, &i, 

eo 



H^B^V 


[ oil INDEX. ^H 


^V ruB 


M«t 


Cmn lUiutt«tins tli« oanill- 


Coldueam, I'hjnolapNl tf 


6on «( niiiw b MOte 


fctuor , , 3<3 


b-oul -HI 


rfctM on die otiiw 372 


— — in chrunio ptuX 1£3 


Iluntmilia acticn 


— — iainUrrnJ (ifSU 144 


of . . . sn 


— illnBlraUsB Ihc mocbiil 


raica for iu adni- 


UMtont; oT Guut 173 


ntBtntian . . 391 


— — of ohjM^ gool. 




villi •ita&ilTi 


timuof . . }BS 


^m «)i*Ik tlonc*, ITS, 


COU, effut of . . . £43 


^B isi. n-i, i8t. us 


Concrvllcoa, gontjr . M 


^^■^ — — dcpjaiu on r»t 


OuU,M..*i*«io( . . la 


W odIj, mi, lati, ics 


Cranip in g^ut . . . $10 


K^^ — > witti DO extciual il»- 


Cronlkinr'* ifiHtelian of k 


^H uxlU SOO, SDl, tOi, 
^B S04, SOS, 309, SOP, 21 1 


gouttiubjeet . . , 17C 
Cantn-*dItUini«fsnt . 30* 


— illlUtntir« uf rbeu- 


Tl«n «f Ibo n*tu« ^^m 


mMtiid aiihrl^ £01. 


of font '"^^^H 


MS; SOU. C«fi, let, A03, 


^^^^H 


509. S70, £71 


^H 


C*BM«af(Dul . . ,313 


— Bioltinjt . ■ . 579 


DtnniiTt PviiitraMBa^ ^^H 


— pndlipowiig . . 243 


ricnof . . IS ■ 


Ocliii% riemof . . . C 


DeaiiaBauitloa of mlldf . . M H 


QLklk-itaBM, ialfiTOMo]uosj>- 


Liia(ii«^«rsiMt . fin H 


ptkneo* (if . J7 


llinrbonttM , . . ISI ■ 




Diet, in aniU goirt . 31S ■ 


^^ — ■ tttuvencjafMmx- 


'- in cifamiio BDnl . . t09 ^^^^ 


^^H r«nto of . . At 


Dinrtiva atjaiu, gonl <J . 4M^^H 


^^H — ^ ooour only is tn« 


ke. . . . . STl^^B 


^^H gODl , . , Eff DiciiuT^m mJi . . BM^^^H 


^^B _-. aitlMMronl]r63; 1S1 


DiioMa in caimealiM wiili ^^^M 


^H — tratmoitaf 448 


r>«t ■ STl^^H 


^^m 01m11d% OB efiNi of EoIcUma 


DiBfoUet . . SM^^H 


^^H 00 urItM . 3TS 


Djqapiilt a owe of sont 3*i^^^| 


^^OlMlUnhunwatcn . , 4ii 


ssl^^H 


daitOmM, Dr., on had-pM- 


a 1 


nning . . 27S 


-^ «i rfBjrt of wlehl- 


E«*, canty aftdionrf 03,191^^^1 


cam on Brino . i7t 


MM^^^^^I 


Cliranle scat . . . . .'3 


Bj«, . -M^^l 


^^ tmttstDt of . 401 


Mom*, Id BDUt . 34, ^j^^^H 


dial ud regi- 


Bnutiet, In (oat . . I^^^^^l 


men in , tut 


Bm »»(«n. in gotl . . W^^^H 


Oidte, » MOM of gMt S6T, CUl 


Gswouc, value (/, in gout . MS^^^| 


diottla, luflDtDM of . . 308 


^^^H 


ColdiEd* . , . . MS 


^H 


^ tffaibor . S« 


^^CoMimin . . sae 


PAi^im, nn Uw irfntMe V 


^^B uoItiLi nf . , 344 


ofleiKl . .fiPS^^I 



INDEX. 



«1S 





paot 




tiOI 


Fenneoted liquors, a catuc 




Hafgartii, Dr., vicirs of 


CZ2 


OfgDDt 


251 


Headache, goatj 


G14 


Permgiiioos pcepar&tions 


439 


Heart affected h; gont . . 


COI 


Frajciniu Excelsior, {earno! 




Heberdcn, on thcaequehe of 




in gout . 


423 


gout . ■ . . 


u 






Hellebore, vbite, ita action . 


396 






llereditar; prediepoaition to 




G. 




gout 


243 


GAracNiK, Dr., tIbw of tLc 
catare of gnut . 

OD blood-lettiog . 

Galea, Tievs of . 

Gastciii, vaUra of . . . 


310 


Hermodacty I as 
Jlippocratea, Tiews of 
Hombargh waters . , , 


3sa 
s 

483 


sss 

7 

4»J 


Hjpochoudri.isiB, gouty . . 
Hysteria, gouty . 


514 


Gout, ita antiquity 


1 






— lUcieDt kpowlcdge of. 


i 


I. 




— BjnonjmB of 

— origjQ of word 


s 


ImiQESTios, a causoof gout 263, 


^ acute 

— special affodluD o 

great toe in , 

— eiccptionai caMB of . 


17 


Iron preparations, in gout . 


£0X 

439 


21 


Inegubr gi^it . . , 


487 


n 


— affecting diges- 




-' characters of iiiilamma- 




tive organs 


403 


tioa in 


25 


— — heart . . 


501 


— lUaDlating acats rheu- 




— - - respiratory or- 


fi03 


matisiu . . . 


S9 


gans . 


— recnrrence of 


31 


— — • urinary organs 


604 


— chronic 


53 


— — eye and ear . 


500 


— iUoetratire cases of 


GO 


— — aLiu 


60S 


- - miaplaced . 


4S7 


— —V nerrous anc 




■ ■■ irreglar forma of . . 


J87 


muscularsyft. 




-- retrocedent 


491 


terns . 


510 


' - blood in , , . 


eo 


— fjiusing cramp . 


ClU 


-— blister, fluid in . 


123 


— causing neunjgia . 


GI3 


— perspiration in . . 


129 


— treatment of 


510 


— urine ia . . 


131 






--- inoTtnd anatom; of 


172 


J. 




causes of . 


212 




— nature of . . . . 


2d6 


JouN80\, Dr. George, ouBu 




— treatmeat of acute 


341 


croBcopic appearance of 




— — chronic 


401 


kidneja in gout . 


£30 


— — retrocedent 


CIO 


Jones, Dr. H. flenee, on the 




— — irreguUr . 


520 


acidity of urine 


138 


- diagaosiB of . . . 


B72 


— on wines . 


2;o 


— prognosis . 


OSS 






Quatacuni, ita tsIuc ,403, 


CSl 


K. 




U. 




KiPirtT^ in gout . 
— microicopic appear- 


229 


UiTiuiD, Mr. A., on ddcr 




ances of - . 


2"fi 


is causing gout . 


691 


Kiasingen waters . . , 


4SS 



^^CIHHHH 


eifl IKOBX. ^H 


L. 


j^H 


tMM 


pjU^^^H 


tus^ ladanM d^ m k prv- 


OXUM And In gowtr UMd 1^*^^| 


tUipwSue «M*r ut 


be(M7 l*ii|*- ^^ 


SMt . . S70,SP3 


raliea. ... 133 ■ 


— •nanptihiUlj of goutjr 




r<UJ»Dia l4 iu in- 


^^^M 


UncDM . . STS 


^H 


bloodln . . . STS 


PirnoiMT of (OBt . . 9tt J 


Ii««bM^ In MBto gootf ia- 


Fan|itnUsD in coat . . 19 ^^H 


■kmiua^am , . 30(1 


rstft,I)T.,a>MaorcoiillfMlal ^^M 


UtUkMltaineout . . 410 


alVicby . . Ut^^M 


Local icMtdics In gont . 303 


Forttr, pnllfpc^ la goM 3M ^^H 




Partiud HviJ«r In fnt . 4M ^^1 
PaluhMlttiacnl . . 419 V 




Pndbptoing MDMa «f god . X4S 1 


HL 


rrecamiofpot . UI^^H 


rropbjrlMtae Ircntmcnl oT ^^H 




put . . £M ^^ 


xuiiiSMitr . .lis 

H*rlMfa*d mUn . . . fSS 


Patg»tivM la tbo tiwiaoit ■ 
of goat .940 ■ 


Uunniriili U the tmtment 


Ffmont wnltfi . . 4$J ■ 


of gout . . SGI 


^^^B 


HincntI wrvCeii ia goat . . 4tt2 


^^^H 


- — • o( Ail-Ia-Chipctlo 478 


^H 


~ — o(3a,iea]Mna . 47» 




ofButoB . , iS3 


QtrmnlaBnit . . 439,553 1 
^ bwMMt ol^ m aria ^^H 


oflVplitt , . 484 


•tu . . . u» ^H 


afTidw , . in 

' - — • tfWItaladoi . 47t 


^H 


of VlMted . . 458 


^H 


Uoon, Mr., cnOiraijoMan- 


^^^H 


tlon* . . 7« 


Bamm b (osi . itt -^^H 


on trefclnnDt of . M 


BomdM^ ImbI . . . »9 '^^1 


Hortud vMoaj U goai . 171 


BwpMitiatT wffpi. f»al<f. 503 ^^H 


Mulder oa vino* . . . 30 


BMmNdntBMt . 401 ^^H 


lHueaUr (pUn, gaaiat . flio 


imlaonlcf filS V 




BhwmMlt (out . , 5S3 fl 




BbraualiiB. (tiOmoiMl ^^H 




•fi^H^^faM ^H 


K. 


pMt . . CTt ^V 


MOdHtM of ■ 




blool ia . . cei ■ 


K»iin1i«r;ant . . . !S6 


oiMUr . . Ul ■ 


, Callen'* tow of . 300 


filitoMatiiU BtUiritii . . Ul ■ 


1 tiianj fnlM*' 


CUM UloKtallT* ■ 


1 tIm" of . 301 


of . . S4I ■ 


f Ajlttor'B ti(ir» of >16 


dMcrlsUMW . fi^ ^^ 


Ktnon* tjntm, (out of lh« £10 


tn»taM«f . &SI ^H 


Nnral|[>, gcmt; . . £18 dikgnMbtf . UTS ^^M 



INDEX. 



air 



p. 

not 

SiLurea in gout . . . 407 

Sclivftltiaclk watan . . i85 

ScndAiDora, Sii C, on tlie in- 

floenoa of hsredi- 

Mrj prediipoaitiDii 213 

— tkbis ihowing the 
period of first at- 

Uck. . S17 

— Mat of inSuDDia- 
tion in fint ftttKic . . 22 

Souon, inflaence of, io gout . 268 
Sax, iaSueiice of . . 245 

fikio, gout (Seeling (be . . 508 
Boden vaUn .483 

SpavaUn . . . 485 

Spinal conl, gout of . , 51 7 
fipiriti, diatilled, their iu' 

flueDca in indueing gout 252 
Stomach, goat of . 4B2, 4B8 
Sjdeaham's deKripUoD of a 

fit of gout . 4a 

— of ehrooia gout . 88 



T. 



FICK 

UiiTE of Mxla, iu gontj 

blood . . »i 

— — alvaja de- 

posited, in 

gDutj in- 

" fiammatloQ 

'214, 310 

— — the euential 

eoiutitueiit 
of ehilk- 
Btonea , . G7 
Urea, in goutj blood . . 12lt 
Drift add, in blood . . il4 

— limple method of 

detecting, is blood 07 

— chaogea in, daring 

decomposition uf 
blood . . . 102 

— ita oonctjuit preaeocv 

in goatj blood . 104 
^ in blister lerum . 123 

— in blood in lend-poi- 

Baaing . . . i'S 

— cbtneten of . . 367 

— oompMilion of . , 283 

— phjeiotogj uid pa- 



Tim PI* AH EN T, influence of 250 


thologf of . . 290 


Tepliti nten . . 434 


— producti of ilsmeta- 




analjaia of . S88 


morphoais . . . 290 


Todd, Dr. 


on gout; kidne; 229 


ITrinarjp organi, gout of . S04 


— 


onbligterainGOUt 361 


I'rine, chanutcn of health; IU( 


TophaceooB depoeits , . 5S 


— in acute gout . .144 


TraltianoB, Alexander, Tiewa 10 


— in cbrooic gont . 163 


TRstmeDt of gout . . .341 


— in tlie intcrvali of the 


— 


with albumi- 


fiu . . . 1«4 




nnria . . 440 


— freqaeat preMnco of 


— 


of acute gout . 345 


albumen in . . 163 


— 


local, of Bcote 


— mieroaeopic cbarMten 




gout. . . 350 


of, in chronic gout 168 


— 


clirDuic gout . 401 


— in lead poiauuing . . 277 


— 


chalk .slonea . . 443 




— 


goutj ibBCeuea . 440 




— 


ptopbjilalic, of 

goot . . £80 




— 


ofirr^ular gout 51^0 


V. 


— 


or rettocedent 






gont . .510 


ViRiTRia . . . .307 


— 


of rbenmatlegout SGI 


VeratmiD album . . . 3S6 


— 


ofrbenmatoidar- 


Vieh; wateri, in gout. . 463 




thritil . . 5.'>1 


— analjaiiof . . 590 



HI^HI^^^I 


613 




W. 




^oS^H 




FAOB 


^ildboj n-nUn . . fri ^M 


\Vj.TEa9, mineral, in goal . 


1G2 


— — iuia1;su of . S9S ^H 


Watson, Dr., nmarlu oa col- 




Vnnas, u cou>«i of glint . 25S ^^t 


chicum in gout . . 


SBO 


— amuDDt of alcobol in ^| 


Wntson, Mr. Heniy, di«a»o- 




different . . S39 ^M 


llna of a govlj sabject . 


17S 


WoUuton, Dr., anitliruf of ^M 


WiGsbailaa nalats, in gout . 


ija 


duklk-BtoDcs . . , G8 ^H 


— — anii\jRBuf , 


5ve 


Wood, Dr., oD dJBT, iaciui- ^H 


-— — elFocls of, on 




iiig gout . sa ^H 


tlie uilae . 


Mi 


^M 



THE END, 



■iRADBCnV JlN'D EVA.VS. TRINTCHS, n'llTTeFRlAlt^ 



^y tht $ame Author, 

MEDICINES, 
THEIR NATURE AND VALUE 

IK laa 
TREATMENT OF DISEASE, 

ExsaAcna tbi 
"S3SENTIAIS OP MATSEIA UBDICA AND THBRAFSDTICS.' 

OS 13 VOLUilE. 



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DH, WALSHE ON DJSEASB3 OF THE HKABT 
AND 0B8AT VBSSBLS, litcladlBg lh« Pritljtw af FbTMBl 
DIuDoria. Thinl BiUlien, BcrlMd anil stMltr JUinnL BmtU 
8nt, ISi-Srf. 

ir. 

BB. WALSHE OS DISEASES OF THE LUNGS. 
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V, 

DR. KinVAKD SMITH ON COXSUSIPTION, 
iu ml; >i.J BatatdtabU SUfif. Small Sto., lOi. dd. 

VL 

Dlt. KDWARD SMITH— HEALTH AND DISEASE 

AS ILLUSTKATBD BY TUB CYCLICAL CHAJIGE3 Dl THK 
HOMAN SVSTBU. WiJi lO If^nioK i<<ull Sk, lOt. «rf. 
doUi. 

VII, 

DR. BALLAHl) ON THE PHYSICAL DLVGNOSIS 
OF DIS^ASKJ VV TUU .UiUOUBN. liauK, U M. 
nil. 
MB. QUAIN OX DISF,ASP-3 OF THE BBCTUII. 

SmmkI Klitioa. C«l«(Btd Jlliuttsll.««. 12aim 7t. M. 



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Edition. Ihflroughlj' RrrisML Willi lUoMMJona on Stnl and Wood. 
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ILLUSTRATIONS OF DISSECTIONS, in a Sena <rf 

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Dh. ROBERTS ON URINARY AND RENAL 

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Or. GARROD on GOUT AND RHEUMATIC 

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Dr. HILLIER'S HANDBOOK OF SKIN DISEASES, 

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Dr. WALSHE ON DISEASES OF THE HEART 
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IK. 6t/. 

Tlic chief iddiiiant have htai tn*At in the prKtitsI pottiom of tW book. 
Several aUcclvoni. of which little or do Kccouat luid been given in ihc jiRinaai 

ciljliiiniv BtT now irealod of in dclniL 

Dr. WALSHE on DISEASES OF THE LUNGS. 

ii)i1ii>lii>K ili< I*rioci|>1e)i of Itipical Iiiai-eotu. Thiid biltlion. KeriiM 

anil f-retily ICdIui^ Snull 9to. is<. 6rf^ 

Deaciipliotut of Knreral diacuM, yawniottXf onutlc<f. ait now introdnnd ; 
the caatn and mode ol production of^ the man impottaM allecliaiii^ •» Cw m 
tb«y poM«« pnctical Mgnlfionce. ate nKdncdy iaquind iMoj aad lb* 
diaerioui and pragnoab of each complunt are wore OMnpIele^ eooriikrvd. 
The aectknu on tieatineni and dimnte have bceo laigelj eateardM. 



^^S diagnoui 
^^k Thcaecl 



Db. EDWARD SMITH'S 



PRACTICAL DIETARY 



fiir l-'jnillin, Schuola, nii>] the Ldbooring CUuu. 
Small Hv». ii. bJ. 

"IV. SnillhMoiikii Mr fat Ih* ibmI UHlbl wbnTtiemipciiiall lli»nninioiJuu«i»aa 
CMiiKlfrf vnh (h* rtsuLuloa of load. latolWf <i>r iDdhidiiali w fanillca,'^t«/an 



"^V 



Or. MURPHY'S PRINCIPLES AND PRACTICE 

of MIDWIFKRV. Second .1111 1 jjrcalijr tmptovtd Edition. With many 
llluatmidiu. Complcu in i tol. sniiiU Uvo, at. 6d. 

"Tht uli]«1 nf !>' lliinitiy lui tvrii (a ml* hii leclura aa ncac^eallr uxfiil u 
pMaihlc*-ArvriUM'^ir^7«>~>/. 

" III iliioiMinc lh( IraumtM, lit Muqihy 1> not nnlcnl vhb btiiia dmm bWowy 
min. tui nhn omMAvUy M Ue pnnciiilai -m which h* am: uhllcho difHttm* an 
(Itar. aiplicil, mubiI. ud cmiixntlf pncnodi'— /'■rf'M ^aniH^r Tim mili/ jil/Jiial 
Siiimi. 

Mr. QUAIN on DISEASES OF THE RECTUM. 

Sciuiiil I'.iliiiQiii, CulourcJ I'latcK, 7«. U 

Dr. EDWARD SMITH ON HEALTH AND DISEASE, 

u IIJuUiMcd by the Cyclical Cbuisct in tbe llnukui Syalcfu. SihaU 
Svo. VU.6J. 

"On* id Ibt mou nnatbUi, nlutUa aad luaful hmki, -n ■■■•« tvtf aid (rlih.**— 



Dr. EDWARD SMITH ON CONSUMPTION, IN 

lli. F.aily oiiil Remediable .'^togc*. Small Svo. icu. bJ. doth. 



■\t]e aiuiner In vhffh lie 
•mklYi vhV-h Ti« ha^ dir«clAj ltl« 



'Wrniiiii niiv iak« liBvt nr Ih Kniiih, n| iimj« i, lii uiaiilii ilw iii» lilifc iiini »frti 
he hii iii*T»l.pn4 Ihe wriiqanaiaaf a» dhaaaa ; and af Iha lahal 
KUl ln< iiliiiaiViiii ilMlMtiiiliiMiiil bioaiMfaia iu iKJiiiHBt' 

Dr. HARLE Y on JAUNDICE: ITS PATHOLOGY 

ANU TKKATULNT. With UieappliaitionofPhyaolagiMlCbeniitir 
\o Uie Detection anil Titauucnt or UmM* ti Ihc Liter and PutocM. 
8vu. 7/. &( 

"TUiCaaiiiaiMlvtaiidTaliuliIa bw*. *— JTia-h V t Ahint*. 

"On Innmcnb Dr. Ilafter haa aaint TlluaUt Taataikl' — Brittdt mmd Fttifn 

Dr. HARLEY ON DIABETES: ITS VARIOUS 

Fof nu and dilTeicnl TmUncnii. SouU Svo, 31. 6i. ftul PttklithtJ. 

Dr. HARLEY ON ALBUMINURIA, WITH OR 

WITHOLT UROI'SV i it* diiKtnal Fonn*, PMlulosy and TreAlminL 

sipbUSto. u.m y-ttiiitdr. 
QUAIN AND WILSON'S ANATOMICAL PLATES. 

901 rute*. Royal fotk). 3 vob., balf-bonsd morocco, 5/. sf. Plain ; 
S/. Si. Coloured. 

*a* J^ aba in Divuiamt (itf^r^tttjf) u tmAr— 

ruLiKa csLOcaaiK 
Uunn (}■ FkiWal . • . . . Uaih ^1 i • • • ■ 



Vakuaa fiafte* . . . 
HnoM tl*HMo . . . 
Viaraaa Iji Italaal . 
BoMHft MUMom (^ PlaM^ . 






> « a 
I M a 
I M n 
too 



Dr. HOFMANN'S MODERN CHEMISTRY, EX- 

PERIMENTAL AND TIIKUKKTIC. Mtaj lUu^mtioai. Soull 

"liitiBllMvuoi wtMulnindncriaBWcteialMiT.- otJ M mA <■ pa^aw i» Mg^ni 
■nlu*,—* nlus vhKh ■■ eqiullir pvl •• hs Mulaib unr M As ki'ij«m, ^iJ ■• A* kow 
who hu (ptnl )p«r\ ta waching ii.'"— *M«tiT. 

"!■■•■ iHr ud conci-a ■■DUiuiioD of it» am ncwl iHwt ■nnraliiaJ h* aaJm 
ckodML and o( ihc npeiUncauI |inc«H bjrvhWi lh«*u HVfomAi tl ■BriiMb«to*» 
haodt of **«>r jnuoj ■■s'e'U ^ w idBKc^-OBvCntr ^fonw^T' £>■■■». 



BARON LIEfilG'S WORKS. 






■jbry;— Anlaint LivaiiKi. Kuinphiy DwT. I* 
bMMiaA al i)u wk ; lo Dm. Id Hfciidii pro 



■abnriDt in his noftterV in Juction tflc fviilu «f «D iirwB * aaA coBtaumr towA^- 
Ihin, lod aiiitilying in brcn dtr*cn by hla <m hKoataiMt iiMiirhii. Llitt( Mi tati am 



CIV. IB H^eiidid pnHMuiiM. lu IkWft lu (tsrioH 
inJuction Ibc fviilu «f «D iinni 
4CI1 by hh wtt ibcofflparwilt 
■ conHfiMt wtinltt 1b« aiAt tt «*a»lc ct 
ntCMTUef askuKoK bum hoxclbTih to (11 ifam rpmc'— /abn 

THE NATURAL LAWS OF HUSBANDRY. 8«. ra.Kt 
FAMILIAR LETTERS ON CHEMISTRY, Ja in 

Relationi to nipiola^. DJci«fic^ Auncvlniie, ConiBtcTCi^ anil I^oKlkal 

Economy, Fourth Eiiilion, Enlarged. Small Sio, 71. &/. 

LETTERS ON MODERN AGRICULTURE. Simll 

Svo. tl. 

PRINCIPLES OF AGRICULTURAL CHEMISTRY. 

Small Svo, 31. 6J. 

HANDBOOK OF ORGANIC ANALYSIS. SnunSra-s.. 
BUNSEN'S GASOMETRY. The leading Phy»ical and 
LARDNER'S HANDBOOK OF ELECTRICITY, 

MACJNKTISM AND ACOUSTICS. New KJilion. Scvwilli Tboy- 
Mnd. EtlStwl *i\A compltuxl u> UiepraaeBl line by G. C. Foam, BJL, 
P.C.5., FR>r««OT of Exp^rinwntnl ra)r«c» ia Unmntty CoHcf^ Lo*do^ 
400 lUiutrsliniu. Small ftnx y. 

L'NirOKM WTTB THR ABOVB,— 

LARDNER'S HANDBOOK OF MECHANICS. 

357 Itlculrations. 5'. 

LARDNER'S HANDBOOK OF PNEUMATICS, 

HYDROSTATICS, AND HEAT, jgi lUiulralloat. y. 

LARDNER'S HANDBOOK OF OPTICS. 2^ 

Illuacnlioiu. 5'. 
\' neah«Mf*mrl'flumtifarma ttm^lt taunt i^ XatumJ PMlMtfAy, 

LARDNER AND DUNKIN'S HANDBOOK OF 

ASTRONOMY. i.<7 IlluiCnillon*. Small Svo. 71. &/. 

HENRY'S GLOSSARY OF SCIENTIFIC TERMS 

for GENERAL USE. 1»M. %». 6d. 



LONDON ; WALTON AND MABERLY, 137, GOWER STREET. 



LANE MEDICAL UBRARY 



To ivoM One, litis book tUionlil be returned 
on or bvforo tho dkto liut ctamped below. 






KrS4 The nrtturs inii trev 

!«*.•» m«»nt of fput. 




it*